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ANATOMY 

OF  THE 

ARTERIES  OF  THE  HUMAN  BODY, 

WITH    THE 

DESCRIPTIVE  ANATOMY  Of  THE  HEAET. 


PUBLISHEES'  NOTICE. 


In  compliance  with  authority  from  the  Surgeon-General  of  the 
United  States  Army,  the  present  edition  of  Power's  Anatomy  of  the 
Arteries  is  issued  for  the  use  of  surgeons  on  the  field  of  battle  and 
in  army  hospitals. 

Besides  the  excellent  illustrations  in  the  English  edition  (from 
drawings  by  Dr.  B.  Wills  Richardson),  numerous  other  engrav- 
ings, executed  under  the  inspection  of  one  of  our  most  distin- 
guished American  anatomists,  have  been  inserted.  In  the  general 
execution  of  the  work,  special  reference  has  been  had  to  making  it 
of  the  most  convenient  form  for  the  surgeon's  use. 

We  believe  that  it  will  be  found  an  indispensable  vade  mecum  for 

those   engaged  in    the  delicate    operations    incident    to   military 

surgery. 

J.  B.  LIPPINCOTT  &  CO. 

Philadelphia.  Sept.  1, 1862. 


ANATOMY 


ARTERIES  OF  THE  HUMAN  BODY 

DESCEIPTIVE  AND  SUEGICAL 


WITH    THE 


DESCEIPTIVE  ANATOMY  OF  THE  HEAET. 


BY 

JOHN  HATCH  POWER,  M.D. 

FELLOW,  AND  MEMBER  OP  COUNCIL,  OP  THE  ROYAL  COLLEGE  OP  SURGEONS;  PROFESSOR 

OF   DESCRIPTIVE  AND   PRACTICAL  ANATOMY  IN  THE  ROYAL  COLLEGE  OP 

surgeons;  SURGEON   TO  THE  CITY  OF  DUBLIN  HOSPITAL,  ETC. 


AUTHORIZED  AND  ADOPTED  BY  THE  SURGEON-GENERAL  OF 

THE  UNITED  STATES  ARMY  FOR  USE  IN  FIELD  AND 

GENERAL  HOSPITALS. 


PHILADELPHIA: 

J.  B.   LIPPINCOTT  &  CO. 
1862. 


Entered  according  to  Act  of  Congress,  in  the  year  1862,  by 

J.  B.  LIPPINCOTT  &  CO. 

in  the  Clerk's  Office  of  the  District  Court  of  the  United  States  in  and  for  the 
Eastern  District  of  Pennsylvania. 


'61 


PREFACE. 


The  present  work  has  been  undertaken  chiefly 
with  the  view  of  assisting  the  student  whilst  engaged 
in  the  study  of  Practical  Anatomy,  and  of  affording 
him  such  practical  information  in  connection  with 
the  Anatomy  of  the  Arterial  System  as  may  be  of 
advantage  to  him  long  after  his  studies  have  been 
completed. 

For  the  purpose  of  effecting  these  desirable 
objects,  I  have  endeavored  to  simplify  as  much  as 
possible  the  anatomical  details,  and  to  bring  to- 
gether such  material  facts  in  relation  to  the  ope- 
rations upon  the  principal  arteries  of  the  body,  as 
may  lead  to  correct  conclusions  relative  to  the  treat- 
ment of  the  various  accidents  and  diseases  to  which 
these  vessels  are  exposed. 

The  recent  alterations  which  have  been  made  by 
some  of  the  licensing  bodies  in  these  kingdoms 
have  rendered  their  examinations  more  demon- 
strative in  their  character  than  heretofore;  and  I 
trust  it  will  be  found  that,  in  the  arrangements 
which  I  have  adopted,  the  student  will  receive  such 

1*  5 


'1 1:2 


6  PREFACE. 

assistance  in  this  respect  as  the  improved  mode  of 
examination  would  appear  to  render  necessary. 

I  have  not  overlooked  the  fact  that  there  are 
many  practitioners,  particularly  those  in  rural  dis- 
tricts, who  do  not  possess  any  opportunity  of  refresh- 
ing their  memories  upon  anatomical  points  hy  actual 
dissection ;  and  I  am  not  without  hope  that  to  such 
the  present  volume  may  aflbrd  some  useful  hints  as 
to  the  relations  of  those  blood-vessels  which,  from 
time  to  time,  may  become  the  subjects  of  their  ope- 
rations. 

The  Illustrations  have  been  executed  from  draw- 
ings made  expressly  for  the  work  by  Mr.  B.  Wills 
EiCHARDSON,  Examiner  in  Anatomy  and  Physiology 
in  the  Eoyal  College  of  Surgeons,  and  late  Demon- 
strator of  Anatomy  in  the  Carmichael  School  of 
Medicine.  The  elevated  position  to  which  this 
gentleman  has  been  raised  in  the  College,  and 
which  he  continues  to  fill  with  so  much  honor, 
sufficiently  indicates  his  reputation  as  an  Anato- 
mist. The  accurate  and  beautiful  plates  of  Tiede- 
man  and  Cloquet,  of  Professor  Quain  and  Maclise, 
have  been  rendered  available  for  the  illustrated 
portion  of  the  work.* 

I  cheerfully  acknowledge  my  obligations  to  the 
labors  of  the  late  Professor  Harrison,  Professor 
Alcock,  and  particularly  to  those  of  my  former  col- 
league in  the  Carmichael  School  of  Medicine,  the 
late  Dr.  Flood.  In  the  year  1850  I  brought  out  a 
new  edition  of  this  last  gentleman's  work  upon  the 
arteries,  which  has  for  some  time  since  been  out  of 

*  Additional  illustrations  have  been  inserted  in  the  American 
edition. 


PREFACE.  7 

print,  but  of  which  the  principal  part  has  been  em- 
bodied in  the  present  work. 

The  greater  number  of  the  illustrations  have  been 
executed  by  Mr.  Oldham,  of  this  city,  and  the 
remainder  by  Messrs.  ButterT\^orth  and  Heath,  of 
London.  It  would  be  superfluous  to  say  any  thing 
here  in  praise  of  Mr.  Oldham  as  an  artist:  his 
talents  are  so  well  known  and  valued  as  to  render 
such  commendation  upon  my  part  unnecessary. 
Messrs.  Butterworth  and  Heath  are  also  well  known 
as  artists  of  considerable  merit  and  high  standing 
in  their  profession. 

John  Hatch  Power. 

95  Harcourt  Street,  Dublin, 
October,  1860. 


CONTENTS. 


PAGE 

PREFACE 5 

Descbiptive  Anatomy  of  the  Heakt 19 

Preliminary  Directions 19 

Pericardium 20 

General  Description  of  the  Heart 22 

External  Surface 24 

Right  Auricle 27 

Tuberculum  Loweri 28 

Fossa  Ovalis 28 

Foramen  of  Galen  or  Botal 29 

Annulus  Vieussenii 29 

Great  Eustachian  Valve 29 

Lesser  Eustachian  Valve 30 

Openings  of  the  Venae  Cavse 30 

Venoe  Thebesianae 32 

Left  Auricle 32 

Right  Ventricle 34 

Infundibulum 34 

CarneaG  Columnae 34 

Chordao  Tendineoe 34 

Tricuspid  Valve 35 

Valvular  Septum  of  Lieutaud,  of  Right  Ventricle 35 

Functions  of  the  Tricuspid  Valve 36 

Mr.  Hunter's  Views 36 

Mr.  Adams's  Views 36 

Mr.  King's  Safety-Valve 37 

Left  Ventricle 39 

9 


10  CONTENTS. 

Descriptive  Anatomy  of  the  Heart  (continued).  paqb 

Mitral  Valve  of  Vesalius 89 

Valvular  Septum  of  Lieutaud,  of  Left  Ventricle 39 

Zonae  Tendinosae 40 

Opinions  of  Bouillaud 41 

Relative  Capacities  of  the  Cavities  of  the  Heart 41 

Structure  of  the  Heart 43 

Muscular  fibres  of  the  Heart 43 

Mr.  Searle  on  the  arrangement  of  the  Muscular  fibres  of 

the  Heart 46 

Endocardium 48 

Arteries  of  the  Heart 49 

Posterior  or  right  Coronary  Artery 49 

Anterior  or  left  Coronary  Artery 60 

Veins  of  the  Heart 50 

Greater  and  Lesser  Coronary  Veins 51 

Vena  Galeni 51 

Nerves  of  the  Heart 61 

Superior  Cardiac  Nerve 62 

Middle  Cardiac  Nerve 52 

Inferior  Cardiac  Nerve 62 

Cardiac  Plexuses 53 

Great  Cardiac  Plexus 63 

Superficial  or  Anterior  Plexus 53 

Deep  or  Posterior  Plexus 63 

Cardiac  Ganglion  of  AVrisberg 53 

Coronary  Plexuses 63 

Lymphatics  of  the  Heart 63 

Pulmonary  Artery 64 

Ductus  Arteriosus 54 

Right  Pulmonary  Artery 66 

Left  Pulmonary  Artery 66 

Dr.  Hope  on  the  position  of  the  Heart  and  its  great  Vessels  66 

Aorta 68 

Arch  of  Aorta 68 

Anterior  or  Ascending  portion  of  the  Arch  of  Aorta 68 

Connection  of  the  Aorta  with  the  Left  Ventricle 59 

Sinuses  of  Valsalva 69 

Great  Sinus  of  the  Aorta 61 


CONTENTS.  11 

AoBTA  (continued).  page 

Middle  Portion  of  the  Arch  of  the  Aorta 62 

Posterior  or  Descending  portion  of  the  Arch  of  the  Aorta...  64 

Practical  Deductions 65 

Development  of  the  Aorta 66 

Branches  of  the  Aech  of  the  Aorta 67 

Arteria  Innominata 67 

Veins  related  to  the  Arteria  Innominata 68 

Ligature  of  the  Arteria  Innominata,  with  tabular  view 71 

Professor  Porter's  case 71 

Modes  of  Operation 72 

Common  Carotid  Arteries 75 

First  or  inferior  Stage  of  the  right  Common  Carotid 76 

First  or  inferior  Stage  of  the  left  Common  Carotid 77 

Veins  related  to  the  Thoracic  portion  of  the  left  Carotid. ...  78 

Second  or  superior  Stage  of  the  Common  Carotid  Artery...  79 

Veins  of  the  Neck 82 

Ligature  of  the  Common  Carotid  Artery 83 

The  Hunterian  operation 83 

Brasdor  and  Dessault's  operation 83 

Wardrop's  operation 84 

Operation  in  case  of  wound  or  ulceration 85 

Hebenstreit's  case 85 

Mr.  Abernethy's  case 85 

Mr.  Ellis's  case 85 

Sir  A.  Cooper  first  tied  the  Artery  for  Aneurism 86 

Modes  of  the  operation 87 

Operation,  in  its  inferior  Stage 87 

Sedillot's  operation 88 

Operation,  in  its  superior  Stage 89 

Bifurcation  of  the  Common  Carotid 90 

External  Carotid  Artery 90 

Ligature  of  the  External  Carotid  Artery 92 

Branches  of  the  External  Carotid 93 

Superior  Thyroid  Artery 93 

Branches  of  the  Superior  Thyroid  Artery 94 

Lingual  Artery 96 


12  CONTENTS. 

External  Carotid  Artery  (continued).  page 

Branches  of  the  Lingual  Artery 98 

Accompanying  Veins 99 

Operation  of  Tying  the  Lingual  Artery 99 

Wounds  of  he  Ranine  Artery 100 

Facial  Artery 100 

Facial  Vein 102 

Branches  of  the  Facial  Artery 103 

Occipital  Artery 107 

Branches  of  the  Occipital  Artery 109 

Posterior  Auricular  Artery 110 

Pharyngea  Ascendens  Artery Ill 

Branches  of  Pharyngea  Ascendens  Artery 112 

Transversalis  Faciei  Artery 112 

Superficial  Temporal  Artery , 113 

Branches  of  the  Superficial  Temporal  Artery 113 

Internal  Maxillary  Artery 114 

Branches  of  the  Internal  Maxillary  Artery 118 

Internal  Carotid  Artery 125 

Branches  of  the  Internal  Carotid  Artery 129 

Ophthalmic  Artery 130 

Branches  of  the  Ophthalmic  Artery 181 

Cerebral  Branches  of  the  Internal  Carotid  Artery 138 

Rete  Mirabile  of  Galen 140 

Subclavian  Arteries 140 

Ligature  of  the  Subclavian  Artery  in  the  first  Stage 147 

Tabular  View  of  Operation 147 

Professor  Colles's  case 147 

Mr.  Hayden's  case 147 

Mr.  O'Reilly's  case 150 

Mode  of  Performing  the  Operation 153 

Ligature  of  Left  Subclavian  in  its  first  Stage 154 

Dr.  Rodgers's  case 155 

Ligature  of  Subclavian  Artery  in  its  second  Stage 158 

Ligature  of  Subclavian  Artery  in  its  third  Stage 159 

Application  of  the  Distal  Ligature  on  the  Subclavian  and 

Carotid  Arteries 161 

Mr.  Wardrop's  Operation 162 


CONTENTS.  13 

Subclavian  Arteries  (continued).  pxgb 

Mr.  Wickham's  Operation 163 

Dr.  Hobart's  Operation 163 

Branches  of  the  Subclavian  Artery 166 

Vertebral  Artery 166 

Branches  of  the  Vertebral  Artery 168 

Basilar  Artery 171 

Branches  of  the  Basilar  Artery 171 

Circle  of  Willis 173 

Internal  Mammary  Artery 174 

Branches  of  the  Internal  Mammary  Artery 175 

Thyroid  Axis, 177 

Branches  of  the  Thyroid  Axis 178 

Cervicalis  Profunda  Artery 181 

Superior  Intercostal  Artery 182 

Axilla 183 

Axillary  Artery 186 

Ligature  of  the  Axillary  Artery 189 

Ligature  of  Axillary  Artery  in  its  first  Stage 189 

Mr.  Hodgson's  Method 190 

Manec's  Method 192 

Ligature  of  Axillary  Artery  in  its  second  Stage 193 

Ligature  of  Axillary  Artery  in  its  third  Stage 193 

Rupture  or  Laceration  of  Axillary  Artery 194 

Mr.  Adams's  case 194 

Branches  of  the  Axillary  Artery 197 

Acromial  or  Thoracica  Acromialis  Artery 197 

Thoracica  Suprema  Artery 198 

Thoracica  Alaris  Artery 198 

Thoracica  Inferior,  or  External  Mammary  Artery 198 

Infra  or  Subscapular  Artery 199 

Posterior  Circumflex  Artery 199 

Anterior  Circumflex  Artery 200 

Scapular  Anastomosis 200 

Veins  of  the  Arm  and  Fore-Arm 202 

Vensesection 202 

Aneurismal  Varix 204 

Varicose  Aneurism 204 


14  OONTENTS. 

PAGE 

Brachial  Artery 204 

Brachial  Nerves 205 

Ligature  of  the  Brachial  Artery 207 

Aneurisms  of  the  Brachial  Artery 207 

Treatment  of   the   various    Forms   of   Aneurism   of    the 

Brachial  Artery 209 

Compression  of  the  Brachial  Artery 209 

Modes  of  Operation 213 

Branches  of  the  Brachial  Artery 216 

Superior  Profunda  Artery 216 

Arteria  Nutritia 216 

Inferior  Profunda  Artery 217 

Anastomotic  Artery 217 

Muscular  Branches 217 

Ulnar  Artery 218 

Branches  of  the  Ulnar  Artery 218 

Anterior  Ulnar  Recurrent  Artery 219 

Posterior  Ulnar  Recurrent  Artery 219 

Common  Interosseal  Artery 219 

Muscular  Branches 220 

Anterior  Carpal  Branch 221 

Posterior  Carpal  Branch 221 

Communicans  Profunda  Artery 221 

Superficial  Palmar  Artery 221 

Superficial  Palmar  Arch  and  Branches 221 

Operation  of  Tying  the  Ulnar  Artery 223 

Radial  Artery 224 

Branches  of  the  Radial  Artery 227 

Radial  Recurrent  Artery 227 

Muscular  Branches 227 

Superficialis  Volae 227 

Anterior  Carpal  Artery 227 

Posterior  Carpal  Artery ; 227 

Dorsalis  Pollicis 229 

Metacarpal  Artery 229 

Radialis  Indicis  Artery 229 

Princeps  Pollicis  Artery 229 

Palmaris  Profunda  Artery 229 


CONTENTS.  15 

Radial  Artery  (continued).  page 

Deep  Palmar  Arch 230 

Ligature  of  the  Radial  Artery 231 

Descending  Aorta 233 

TnoRACic  Aorta 233 

Branches  of  the  Thoracic  Aorta 235 

Abdominal  Aorta 238 

Ligature  of  the  Abdominal  Aorta 239 

Tabular  View  of  Operation 240 

Sir  A.  Cooper's  case 240 

Mr.  James's  case 241 

Dr.  Murray's  case 242 

Dr.  Monteiro's  case 247 

Mr.  South's  case 247 

Branches  of  the  Abdominal  Aorta 248 

Coeliac  Axis 249 

Gastric,  or  Coronaria  Ventriculi  Artery 250 

Hepatic  Artery 250 

Circulation  of  the  Blood  in  the  Liver 253 

Umbilical  Vein  in  the  Foetus 253 

Vena  Portaa  in  the  Foetus 254 

Source  of  the  Biliary  Secretion 254 

Kiernan's  Observations  on  the  Liver 255 

Todd  and  Bowman's  Opinions 258 

Splenic  Artery 258 

Structure  of  the  Spleen 260 

Superior  Mesenteric  Artery 261 

Branches  of  the  Superior  Mesenteric  Artery 262 

Inferior  Mesenteric  Artery 264 

Branches  of  the  Inferior  Mesenteric  Artery 264 

Proper  Phrenic  Arteries 266 

Middle  Capsular  Arteries 267 

Renal  Arteries 267 

Renal  Veins 269 

Arrangement  of  the  Vessels  in  the  Kidney 270 

Spermatic  Arteries 272 

Lumbar  Arteries 275 

Middle  Sacral  Artery 276 


16  CONTENTS. 

PAGB 

Common  or  Primitive  Iliac  Arteries 276 

Ligature  of  the  Common  Iliac  Artery 278 

Mr.  Mott's  case 280 

Sir  P.  Crampton's  case 282 

Mr.  Hey's  case 283 

Internal  Iliac  Artery 284 

Internal  Iliac  Artery  in  the  Foetus 284 

Ligature  of  the  Internal  Iliac  Artery 286 

Dr.  Steven's  and  Mr.  Atkinson's  cases 286 

Mr.  White's  case 286 

Branches  of  the  Internal  Iliac  Artery 287 

Glutaeal  Artery 288 

Operation  of  Tying  the  Glutaeal  Artery 289 

Mr.  Lizars's  method 289 

Mr.  Carmichael's  case 289 

Sciatic,  or  Ischiatic  Artery 291 

Branches  of  the  Sciatic  or  Ischiatic  Artery 292 

Obturator  Artery 293 

Branches  of  the  Obturator  Artery 294 

Anatomy  of  the  Ano-Perineal  Region 294 

Lateral  Operation  for  Lithotomy 306 

Internal  Pudic  Artery 809 

Branches  of  the  Internal  Pudic  Artery 313 

External  Haemorrhoidal  Artery 313 

Long  Perineal  Artery 313 

Transverse  Artery  of  the  Perineum 313 

Artery  of  the  Bulb 314 

Artery  of  the  Corpus  Cavernosum 314 

Dorsal  Artery  of  the  Penis 316 

Hio  Lumbar  Artery 317 

Lateral  Sacral  Artery 319 

Middle  Hasmorrhoidal  Artery 319 

Vesical  Artery 319 

Umbilical  Artery. 320 

Uterine  Artery 320 

Vaginal  Artery 321 

External  Iliac  Artery 321 

Ligature  of  the  External  Iliac  Artery 322 


CONTENTS.  17 

External  Iliac  Artery  (continued).  page 

Mr.  Abernethy's  operation 822 

Sir  A.  Cooper's  operation 323 

Branches  of  the  External  Iliac  Artery 325 

Epigastric  Artery 827 

Internal  Circumflexa  Ilii  Artery 328 

Femoral  Artery 328 

Femoral  Vein 335 

Operations  on  the  Femoral  Artery 336 

Professor  Porter's  Operation 337 

Compression  on  the  Femoral  Artery 341 

Mr.  Todd's  cases 341 

Mr.  M'Coy's  case 342 

Dr.  Hutton's  case 342 

Dr.  Cusack's  case 343 

Dr.  Bellingham's  cases 343 

Branches  of  the  Femoral  Artery 345 

Superficial  Epigastric  Artery 345 

External  Pudic  Arteries 345 

Superficial  Circumflexa  Ilii  Artery 345 

Muscular  Branches 346 

Anastomotica  Magna  Artery 346 

Profunda  Femoral  Artery 346 

External  Circumflex  Artery 347 

Internal  Circumflex  Artery 348 

Perforating  Arteries 350 

Popliteal  Space 351 

Popliteal  Artery 354 

Ligature  of  the  Popliteal  Artery 356 

Branches  of  the  Popliteal  Artery 358 

Articular  Arteries 358 

Anterior  Tibial  Artery 359 

Ligature  of  the  Anterior  Tibial  Artery 361 

Branches  of  the  Anterior  Tibial  Artery 362 

Tibial  Recurrent 362 

Muscular  Branches 362 

Internal  Malleolar  Artery 362 

2» 


18  CONTENTS. 

Anterior  Tibial  Artery  (continued).  page 

External  Malleolar  Artery 362 

Tarsal  Artery 363 

Metatarsal  Artery 363 

Dorsalis  Pollicis 364 

Ramus  Communicans 364 

Posterior  Tibial  Artery 364 

Ligature  of  the  Posterior  Tibial  Artery 366 

Branches  of  the  Posterior  Tibial  Artery 367 

Muscular  Arteries 367 

Nutritious  Artery 367 

Peroneal  Artery 367 

Ligature  of  the  Peroneal  Artery 368 

Internal  Plantar  Artery 370 

External  Plantar  Artery 370 

Branches  of  the  External  Plantar  Artery 371 

Some  of  the  Principal  Varietie3  or  Anomalies  of  the 

Arteries 374 


ANATOMY 

OF    THE 

HEART  AND  ARTERIES 


DESCRIPTIVE  ANATOMY  OF  THE  HEART. 

PRELIMINARY   DIRECTIONS. 

For  the  purpose  of  exhibiting  the  heart  contained 
within  its  envelope  the  pericardium,  together  with  the 
great  vessels  connected  with  it,  particularly  the  aorta, 
the  student  is  advised,  in  the  first  instance,  to  make  a 
longitudinal  incision  through  the  abdominal  parietes  of 
about  six  inches  in  length,  the  centre  being  situated  at 
the  umbilicus:  the  bifurcation  of  the  abdominal  aorta 
should  then  be  exposed,  and  a  full-sized  pipe  of  the  in- 
jecting apparatus  inserted  from  below  upwards  into  this 
vessel,  about  two  inches  above  the  origin  of  the  common 
iliac  arteries;  the  injection  should  then  be  directed 
upwards,  towards  the  heart.  By  this  method  the  tho- 
racic aorta,  the  arch  of  the  aorta,  its  relation  to  the  ster- 
num, together  with  its  other  numerous  important  rela- 
tions, will  be  best  seen,  whilst  the  arteries  of  the  head, 
neck,  and  upper  extremities  will  be  much  better  filled 
than  if  the  subject  were  injected  from  the  ordinary  situa- 
tion, the  arch  of  the  aorta.  The  following  dissection 
should  now  be  performed :  a  perpendicular  incision  should 
be  made,  commencing  from  below  the  centre  of  the  cla- 
vicle, and  passing  across  the  second,  third,  fourth,  fifth, 

19 


20  PERICARDIUM. 

sixth,  and  seventh  ribs  of  the  left  side  :  these  bones  should 
then  be  sawn  through,  a  little  in  front  of  their  centres, 
and  the  cartilage  of  the  first  rib  of  the  same  side  divided. 
A  second  perpendicular  incision  should  next  be  made 
through  the  integument  covering  the  sternum,  and  then 
through  the  bone,  keeping  a  little  to  the  right  side  of  the 
middle  line.  The  lower  extremities  of  these  two  in- 
cisions should  now  be  connected  by  means  of  an  oblique 
incision,  and  the  parts  included  within  them  should  be 
next  raised  off  carefully  from  below  upwards,  and  then 
forcibly  turned  backwards  upon  the  front  of  the  neck. 
Whilst  making  this  dissection,  the  soft  parts  lying  behind 
the  divided  portions  of  the  ribs  and  sternum  should  be 
carefully  detached  from  these  bones.  The  mammary 
artery  is  particularly  liable  to  injury  in  this  stage  of  the 
dissection.  By  adopting  the  plan  now  recommended, 
the  student  will  be  able  to  expose  the  pericardium,  and 
to  observe  its  relation  to  the  parietes  of  the  thorax, 
whilst  the  relations  of  the  arch  of  the  aorta,  the  proximity 
of  this  vessel  to  the  right  side  of  the  sternum,  and  to 
the  cartilage  of  the  second  rib,  at  its  junction  with  the 
former  bone,  will  attract  his  attention.  The  same  plan 
of  dissection  may  afterwards  be  pursued  at  the  right 
side,  with  this  difference,  that  the  cartilage  of  the  first 
rib  should  not  be  disturbed,  in  order  that  the  dissection 
of  the  lower  portion  of  the  neck  at  that  side,  together 
with  the  dissection  of  the  arteria  innominata,  may  be 
pursued  with  advantage. 

THE  PERICARDIUM. 

The  pericardium,  properly  speaking,  is  a  specimen  of 
what  Bichat  calls  a  fibro-serous  membrane,  consisting 
of  two  layers  of  membrane,  an  external  or  fibrous,  and 
an  internal  or  serous  layer.  It  is  the  immediate  en- 
velope of  the  heart,  and  of  certain  portions  of  the  great 


PERICARDIUM.  21 

vessels  entering  into  and  issuing  from  it.  Its  form  is 
somewhat  conoid;  the  apex  corresponds  to  the  large 
vessels  in  immediate  connection  with  the  heart,  in  which 
situation  the  fibrous  layer  of  the  sac  may  be  seen  ex- 
tended over  them,  and  identified  with  their  external 
tunic :  the  base  may  be  seen  resting  on  the  cordiform 
tendon  of  the  diaphragm,  to  which  it  adheres  so  firmly 
in  the  adult  as  to  be  with  great  difliculty  separated  from 
it;  it  also  rests  on  a  small  triangular  portion  of  the 
fleshy  fibres  of  the  diaphragm,  to  the  left  of  the  tendon, 
from  which  it  may  very  easily  be  separated.  In  the 
fcetus  the  pericardium  is  but  loosely  connected  with  the 
tendon  and  fleshy  fibres  of  the  diaphragm. 

The  anterior  surface  of  the  pericardium  is  covered  by 
the  thymus  gland  in  the  foetus,  and  in  the  adult  by  a 
considerable  quantity  of  loose  areolar  tissue,  which  oc- 
cupies the  situation  of  the  thymus  gland;  by  the  internal 
and  anterior  portion  of  each  lung  and  pleura,  and  by 
the  sternum :  and  inclining  towards  the  left  side  infe- 
riorly,  we  find  lying  in  front  of  it  also  the  cartilages  of 
the  fourth,  fifth,  sixth,  and  seventh  ribs.  The  sides  of 
the  pericardium  are  over-lapped  by  the  lungs,  and  are 
covered  by  the  pleura3,  the  phrenic  nerve  being  inter- 
posed at  the  left,  and  thrown  more  anteriorly,  so  as  to 
bend  over  the  pericardium  at  a  point  corresponding  to 
the  apex  of  the  heart.  Its  posterior  surface  lies  in  front 
of  the  posterior  mediastinum  and  the  parts  contained 
within  this  region,  more  particularly  the  oesophagus  and 
descending  aorta.  An  incision  may  now  be  made 
through  the  anterior  part  of  this  envelope,  when  its  in- 
ternal or  serous  layer  will  be  exposed :  this  consists  of 
two  portions, — the  one  lining  the  inner  surface  of  the 
fibrous  layer,  and  the  other,  with  which  the  former  is 
perfectly  continuous,  surrounding  the  heart.  The  con- 
tinuity of  these  two  portions  of  the  serous  membrane 


22  PERICARDIUM. 

may  be  demonstrated,  in  the  first  place,  by  tracing  that 
lining  the  inner  surface  of  the  fibrous  layer  from  off" 
that  structure,  to  form  a  cylindrical  sheath  which  en- 
closes both  the  aorta  and  pulmonary  artery;  and  se- 
condly, by  following  the  course  which  that  membrane 
takes  in  forming  partial  investments  for  the  two  vena9 
cavse  and  the  four  pulmonary  veins.  These  two  portions 
of  the  serous  layer,  viz.,  that  lining  the  fibrous  layer  of 
the  pericardium,  and  that  lining  the  exterior  of  the  heart 
itself,  are  perfectly  continuous  with  each  other,  thus 
constituting  a  completely  shut  sac,  so  that  the  vessels 
going  to,  or  issuing  from,  the  heart,  do  not  perforate  the 
serous  membrane,  but  receive  coverings  more  or  less 
perfect  from  it. 

Nine  openings  have  been  enumerated  in  the  fibrous 
layer  of  the  pericardium,  viz.,  one  for  the  aorta,  two  for 
the  right  and  left  branches  of  the  pulmonary  artery, 
four  for  the  four  pulmonary  veins,  and  two  for  the 
superior  and  inferior  venae  cavse.  In  the  foetus  there  is 
another  for  the  ductus  arteriosus.  Strictly  speaking, 
these  are  not  openings  in  the  fibrous  layer  of  the  peri- 
cardium, for  this  structure  becomes  incorporated  with 
the  external  tunic  of  the  vessels  where  they  come  in  con- 
tact with  it. 

When  the  pericardium  has  been  opened,  the  following 
parts  will  be  exposed : — the  anterior  superior  surface  of 
the  heart,  the  two  venae  cavae,  the  aorta,  the  pulmonary 
artery,  the  right  auricular  appendix  and  a  j)ortion  of  the 
auricle,  and  the  tip  of  the  left  auricular  apj^endix.  The 
left  auricle  is  concealed  chiefly  by  the  aorta  and  pulmo- 
nary artery. 

GENERAL  DESCRIPTION   OP  THE  HEART. 

The  Heart  is  a  hollow  muscular  organ  of  a  somewhat 
conical  form,  consisting  of  four  chambers,  grouped  to- 


HEART. 


23 


Fig.  1.— Anterior  View  of  the  Heart. 

A  B  C 


A,  Arteria  Innominata.  B,  Left  Carotid  Artery.  C,  Left  Subclavian  Artery.  D,  Aorta.  E,  Re- 
mains of  Ductus  Arteriosus.  F,  Pulmonary  Artery.  G,  Superior  or  Descending  Vena  Cava.  H, 
Right  Auricle.  I,  Posterior  or  Right  Coronary  Artery.  K,  Left  Auricular  Appendix.  L,  Anterior 
or  Left  Coronary  Artery.    M,  Left  Coronary  Vein.    N.  Anterior  surface  of  Right  Ventricle. 


24  HEART. 

gether  so  as  to  form  an  individual  mass ;  two  of  these 
are  called  the  auricles,  the  other  two  the  ventricles.  The 
apex  of  the  heart  is  formed  (in  the  adult)  by  the  ex- 
tremity of  the  left  ventricle ;  and  looks  downwards, 
forwards,  and  to  the  left  side,  towards  the  interval  be- 
tween the  fifth  and  sixth  ribs :  in  many  subjects  it  is 
curved  a  little  backwards.  The  base  is  turned  upwards, 
backwards,  and  to  the  right  side,  and  corresponds  to  the 
right  side  of  the  fifth,  sixth,  seventh,  and,  sometimes, 
partly  to  the  eighth,  dorsal  vertebrae.  The  posterior  in- 
ferior surface  is  flat  and  triangular,  and  the  anterior  su- 
perior surface  convex  and  more  extensive  :  these  surfaces 
are  separated  by  two  margins:  the  anterior  margin  is 
thin,  and  looks  downwards,  forwards,  and  to  the  right 
side:  the  posterior  margin,  which  is  shorter  but  consider- 
ably thicker,  looks  in  the  opposite  direction. 

The  chief  bulk  of  the  heart  is  formed  by  the  ventri- 
cles, particularly  by  the  left;  and  the  auricles  seem  like 
appendages  situated  at  its  base. 

The  two  auricles  are  situated  at  the  base  of  the  ventri- 
cles, and  towards  its  posterior  part.  When  injected,  and 
viewed  as  one,  they  form  a  crescentic  mass,  the  con- 
cavity of  which  looks  forwards  and  rather  upwards,  and 
embraces  within  it  the  aorta  and  pulmonary  artery. 
The  convexity  looks  backwards  and  somewhat  down- 
wards. The  two  extremities  of  the  crescent  are  formed 
by  the  tips  of  the  right  and  left  auricular  appendices. 

The  two  ventricles  taken  together  form  a  conical  mass, 
which  gives  the  peculiar  form  to  the  heart;  it  is  ob- 
liquely situated,  the  apex  being  directed  downwards, 
forwards,  and  to  the  left  side ;  the  base  upwards,  back- 
wards, and  to  the  right  side. 

The  anterior  superior  surface  of  this  mass  is  convex, 
and  presents  a  fissure  w^hich  runs  from  the  base  to  the 
right  side  of  the  apex;  this  fissure  lodges  the  anterior 


HEART.  25 

coronary  artery  and  vein,  and  a  quantity  of  fat,  and 
divides  the  anterior  surface  into  a  right  and  left  por- 
tion :  the  latter  is  formed  by  the  anterior  surface  of  the 
left  ventricle,  and  the  former,  which  is  much  larger,  is 
formed  by  the  anterior  surface  of  the  right  ventricle. 
In  this  latter  situation,  Dr.  Baillie  has  described  a  white 
opaque  spot,  like  a  thickening  of  the  serous  layer  cover- 
ing the  heart:  it  is  sometimes  not  broader  than  a  six- 
pence; at  other  times  broader  than  a  crown  piece;  "it 
is  so  very  common,  that  it  can  hardly  be  considered  as 
a  disease."* 

The  posterior  inferior  surface  of  the  ventricular  mass, 
which  is  less  extensive  than  the  superior,  is  nearly  flat, 
and  rests  on  the  superior  surface  of  the  diaphragm,  with 
the  interposition  of  the  base  of  the  pericardium.  This 
surface  also  is  divided  into  two  portions  of  unequal  size 
by  a  fissure  running  from  the  base  to  the  right  side  of 
the  apex,  and  containing  within  it  the  posterior  coronary 
artery  and  vein,  and  some  fatty  tissue:  the  larger  por- 
tion is  formed  by  the  left  ventricle,  the  remaining  por- 
tion by  the  right. 

The  anterior  margin  of  the  ventricular  mass  is  thin, 
longer  than  the  posterior,  and  formed  by  the  right  ven- 
tricle:  the  posterior  margin  is  thick  and  convex,  and  is 
partly  lodged,  with  the  intervention  of  the  pericardium, 
in  a  depression  of  the  left  lung,  and  is  formed  by  the 
left  ventricle.  The  apex  is  formed,  in  the  adult,  entirely 
by  the  left  ventricle;  and  the  base  presents  for  exami- 
nation the  following  parts :  anteriorly,  a  funnel-shaped 
projection  of  the  right  ventricle  which  passes  upwards, 
and  is  termed  the  infundibulum,  and  from  which  arises 
the  pulmonary  artery:  on  a  posterior  plane,  concealed 
by  the  infundibulum,  and  more  to  the  right  side  than 


*  Baillie's  Morbid  Anatomy,  by  Wardrop,  p.  54. 
3 


26 


HEART. 


Fig.  2. — Posterior  View  of  the  Heart. 


A,  Orifices  of  the  Arteria  Innominata,  Left  Carotid  and  Left  Subclavian  Arteries.  B,  Superior 
Vena  Cava.  C,  Orifice  of  the  Aorta.  D.  Orifice  of  the  Pulmonary  Artery.  E.  E,  E,  Orifices  of  the 
Pulmonary  Veins.  F,  Right  Auricle.  O,  Orifice  of  the  Inferior  Vena  Cava.  H,  Eustachian  Valve. 
I,  Left  Auricle.  K,  Posterior  Coronary  Vein.  L,  Posterior  Coronary  Artery.  M,  Left  Auricular 
Appendix.    N,  Posterior  part  of  Left  Ventricle.    O,  Posterior  part  of  Right  Ventricle. 


RIGHT    AURICLE.  27 

the  orifice  of  the  pulmonary  artery,  is  the  origin  of  the 
aorta  from  the  base  of  the  left  ventricle.  Behind  these 
two  orifices  the  base  of  the  ventricular  mass  presents  a 
circular  fissure,  circumscribing  that  portion  of  it  which 
corresponds  to  the  auricles:  this  fissure  is  very  deep 
posteriorly :  lastly,  the  base  of  the  ventricular  mass  is 
cut  obliquely  downwards  and  backwards  at  the  expense 
of  the  posterior  inferior  surface,  which  is  consequently 
shorter  than  the  anterior  superior  surface. 

Having  thus  described  the  external  surface  of  the 
heart,  we  may  now  proceed  to  consider  individually  its 
chambers,  which  are,  as  we  have  already  observed,  four 
in  number:  two  auricles  and  two  ventricles. 

The  Right  Auricle  is  of  an  irregular  shape;  it  is 
said  to  possess  the  form  of  the  segment  of  an  ovoid :  it 
presents  for  examination  three  walls,  an  antero-external, 
a  posterior  situated  behind  and  between  the  orifices  of 
the  two  vensB  cavae,  and  an  internal  or  the  septum 
auricularum :  and  two  extremities,'' -an  anterior  inferior, 
and  a  superior.  The  antero-external  loall  is  easily  de- 
fined, as  it  is  formed  by  all  that  portion  of  the  right 
auricle  which  may  be  seen  on  opening  the  pericardium; 
it  is  convex,  and  presents  several  dark  lines  correspond- 
ing to  the  intervals  between  the  musculi  pectinati,  to 
be  described  hereafter.  In  order  to  see  the  internal 
surface  of  the  auricle,  we- should  make  two  incisions; 
one  in  a  vertical  direction  through  the  front  of  the 
auricle,  connecting  the  orifices  of  the  superior  and  infe- 
rior vena3  cavse;  the  other  in  a  slightly  curved  direction, 
the  convexity  directed  downwards,  commencing  at  the 
lower  part  of  the  right  auricular  appendix,  and  termi- 
nating in  the  superior  extremity  of  the  preceding  in- 
cision. In  this  manner  a  flap  will  be  formed  out  of  the 
external  wall  of  the  auricle;  and  we  will  now  have  an 
opportunity  of  examining  the  structure  of  this  wall. 


28  RIGHT    AURICLE. 

Its  muscular  fibres  are  arranged  in  fasciculi,  somewhat 
resembling  the  teeth  of  a  comb;  they  have  been  there- 
fore termed  the  musculi  pectinati:  in  the  intervals  be- 
tween these  fasciculi,  the  Hning  membrane  of  the  interior 
of  the  auricle,  and  the  serous  membrane  covering  the 
heart,  are  almost  in  immediate  contact.  A  tubercle 
has  been  described  as  projecting  from  the  back  part  of 
the  posterior  wall  into  the  auricle,  called  the  tuberculum 
Lower i.  If  we  examine  the  entrance  of  the  great  veins 
into  the  auricle,  we  will  observe  that  the  superior  cava 
passes  downwards,  forwards,  and  to  the  left  side;  and 
the  inferior  cava,  upwards,  backwards,  and  to  the  left 
side:  we  can  readily  understand,  therefore,  that  the  por- 
tion of  the  auricle  between  their  orifices  must  of  neces- 
sity be  salient  towards  the  interior  of  this  cavity;  this 
projecting  part  of  the  auricle  placed  between  the  open- 
ings of  these  two  great  veins,  forms  the  tubercle  of 
Lower.  The  use  ascribed  to  it,  is,  to  direct  the  blood 
towards  the  centre  of  the  auricle,  and  thus  prevent  the 
currents  of  the  superior  and  inferior  venae  cavse  from 
directly  opposing  each  other. 

The  internal  wall  constitutes  the  septum  between  the 
two  auricles;  it  is  obliquely  situated,  so  that  its  right 
surface,  which  we  are  at  present  examining,  looks  also  a 
little  forwards.  On  its  lower  portion  it  presents  a  well- 
marked  depression,  somewhat  oval  in  form,  called  the 
fossa  ovalis :  it  is  bounded  by  two  well-defined  ridges  or 
pillars,  one  on  either  side;  that  on  the  right  side  being 
also  placed  posteriorly;  that  on  the  left,  anteriorly:  the 
latter  is  much  stronger  than  that  on  the  right  side,  and 
it  separates  the  fossa  ovalis  from  the  openfng  of  the 
coronary  vein,  and  gives  attachment  to  the  left  cornu  of 
the  great  Eustachian  valve.  These  two  pillars  are  con- 
tinuous with  one  another  superiorly,  so  as  to  form  an 
arch  over  the  fossa  ovalis,  the  concavity  of  which  is 


RIGHT    AURICLE.  29 

directed  downwards.  This  prominent  margin  which 
bounds  the  fossa,  has  received  the  name  of  the  annulus 
Vieussenii.  It  is  not,  however,  correctly  speaking,  an 
annuhxr  projection,  the  pillars  not  being  joined  together 
inferiorly.  That  portion  of  the  septum  included  between 
the  pillars,  and  which  may  be  called  the  floor  of  the  fossa 
ovalis,  contributes  to  form  a  valvular  opening  between 
the  auricles  in  the  intra-uterine  period  of  life.  This 
opening  has  been  called  the  foramen  ovale,  or  foramen 
of  Botal,  although  it  had  been  previously  described  by 
Galen.  The  upper  part  of  the  floor  projects  into  the 
left  auricle  above  the  point  of  junction  of  the  pillars  of 
the  fossa,  and  there  forms  an  arch,  the  concavity  of 
which  is  directed  upwards;  this  can  be  seen  only  from 
the  interior  of  the  left  auricle.  Before  the  second  month 
of  intra-uterine  life,  this  valvular  apparatus  does  not 
exist;  there  is  in  fact  at  this  period  a  direct  communi- 
cation between  the  auricles :  at  the  end  of  the  second 
month,  it  begins  to  be  developed;  and  at  the  seventh 
month,  the  superior  margin  of  what  we  have  called  the 
floor  of  the  fossa  ovalis,  ascends  sufficiently  high  into 
the  left  auricle,  to  cut  off  the  direct  aperture  of  commu- 
nication; leaving  however  an  oblique  or  valvular  chan- 
nel between  the  auricles.  This  aperture  of  communi- 
cation is,  in  the  normal  state,  closed  in  the  adult  by  the 
adherence  of  the  upper  edge  of  the  valve  to  that  sur- 
face of  the  annulus  of  Vieussens  which  looks  towards 
the  left  auricle.  Belated  to  the  opening  of  the  inferior 
vena  cava  and  to  the  fossa  ovalis,  we  observe  the  great 
Eustachian  valve;  it  presents  a  crescentic  form:  the 
concave  margin,  which  is  generally  well  defined,  is  free, 
and  looks  upwards  and  towards  the  right  shoulder;  the 
convex  margin  is  not  at  all  so  well  defined,  being  in  fact 
continuous  with  the  lining  membrane  of  the  anterior 
wall  of  the  inferior  cava,  at  that  spot  where  this  vein 


30  RIGHT    AURICLE. 

and  the  auricle  become  united  with  each  other:  this 
margin  of  the  valve  looks  downwards  and  towards  the 
left  side.  The  valve  has  two  cornua  or  extremities :  one, 
the  superior  or  left  cornu,  is  attached  to  the  anterior 
pillar  of  the  fossa  ovalis ;  the  other,  inferior  or  right,  is 
at  first  united  to  the  anterior  wall  of  the  orifice  of  the 
inferior  cava,  and  then  sends  an  expansion  in  front  of 
this  orifice  round  towards  its  right  side,  where  it  becomes 
lost  in  the  structure  of  this  portion  of  the  vein,  usually 
without  reaching  the  right  pillar  of  the  fossa  ovalis. 
The  superior  or  left  attachment  of  the  valve  contributes 
to  sej^arate  the  fossa  ovalis  from  the  orifice  of  the  coro- 
nary vein,  whilst  lower  down  we  find  this  valve  sepa- 
rating the  opening  of  this  vein  from  that  of  the  inferior 
vena  cava.  In  the  early  periods  of  foetal  development, 
the  valve  is  proportionally  well  marked;  but  it  gradu- 
ally diminishes  as  the  valve  of  the  foramen  ovale  or 
fossa  ovalis  increases  towards  its  perfect  development. 
The  Lesser  Eustachian  Valve,  or  Yalvula  Thebesii,  or 
valve  of  the  coronary  vein,  is  a  small  duplicature  of  the 
lining  membrane  of  the  vein  and  auricle  :  it  arises  below 
the  anterior  attachment  of  the  greater  Eustachian  valve, 
and,  separating  from  it  as  it  descends,  turns  underneath 
the  orifice  of  the  coronary  vein,  and  becomes  attached 
to  the  margin  of  the  right  auriculo-ventricular  opening. 
The  anterior  inferior  extremity  of  the  auricle  looks  to- 
wards the  right  ventricle,  i.  e.  downwards  and  forwards  : 
in  it  we  observe  the  right  auriculo-ventricular  opening, 
the  long  axis  of  which  is  directed  from  before  back- 
wards. The  superior  extremity  of  the  right  auricle  pre- 
sents to  our  notice  the  right  auricular  appendix,  and 
the  opening  of  the  superior  vena  cava,  with  a  smooth 
surface  situated  between  these  two  parts :  the  right 
auric'ular  appendix  is  triangular  in  its  form,  and  situated 
between  the  aorta  and  right  ventricle :  its  base  is  con- 


RIGHT    AURICLE. 


31 


Pig,  3, — Interior  of  Right  Auricle  and  Ventricle. 


A,  Superior  Vena  Cava.  B,  Aorta.  C,  Musculi  Pectinatl  of  the  Right  Aaricnlar  Appendix.  D, 
Pulmonary  Artery.  K,  Interior  of  the  Uight  Auricle.  P,  Opening  of  the  Superior  Vena  Cava.  G, 
Anuulus  of  Vieussens.  H,  Fossa  Ovalia.  I,  Kustachian  Valve.  K,  Inferior  Vena  Cava.  L,  Open- 
ing of  the  Coronary  Vein.  M,  Valve  of  Thebesius.  N,  Cavity  of  Right  Ventricle.  O,  Section  of  the 
Right  Ventricle  at  the  septum.   P,  Carneae  Column®. 


32  LEFT   AURICLE. 

tinuous  with  the  auricle,  without  any  line  of  demarca- 
tion :  its  apex  is  turned  transversely  towards  the  left 
side  :  posteriorly  it  is  concave,  and  over-laps  the  aorta  : 
its  interior  is  strongly  marked  by  musculi  pectin ati. 
The  superior  cava  takes  a  direction  downwards,  for- 
wards, and  to  the  left  side ;  its  orifice  is  situated  on  a 
plane  anterior  to  that  of  the  inferior  cava ;  two  j)romi- 
nent  muscular  bands  bound  this  opening :  one  of  them 
separates  it  from  the  orifice  of  the  inferior  cava;  the 
other,  not  so  well  marked,  is  situated  on  the  left  side, 
and  separates  the  orifice  of  the  vein  from  the  auricular 
appendix.  The  inferior  cava,  in  approaching  the  heart, 
takes  a  direction  upwards,  backwards,  and  to  the  left 
side  :  at  first  it  ascends  almost  perpendicularly,  and  then, 
assuming  a  more  horizontal  direction,  turns  abruptly 
into  the  auricle,  immediately  before  which  it  frequently 
presents  a  dilatation.  Its  orifice  is  larger  than  that  of 
the  superior  cava,  and  is  situated  on  a  plane  posterior 
to  it:  it  likewise  differs  from  it  in  its  relation  to  the 
Eustachian  valve. 

A  number  of  minute  openings  on  the  inner  surface  of 
the  auricle  have  been  described  as  the  orifices  of  what 
are  termed  venm  Thebesiance:  it  is  by  no  means  certain 
that  they  are  the  orifices  of  vessels. 

The  Left  Auricle  when  distended  presents  somewhat 
the  form  of  a  four-sided  pyramid,  the  base  of  which  is 
situated  at  its  right  side  and  forms  the  septum  auricu- 
larum;  while  the  truncated  apex  constitutes  the  left  wall 
or  side  of  this  cavity.  At  the  anterior  and  upper  por- 
tion of  this  latter  wall,  where  it  joins  the  superior,  we 
find  the  opening  of  the  left  auricular  appendix ;  and  far- 
ther back,  where  the  left  wall  unites  with  the  posterior, 
we  find  the  openings  of  the  left  pulmonary  veins.  The 
posterior  wall  is  directed  a  little  upwards;  and  at  its 


LEFT    AURICLE.  33 

right  extremity,  and  upper  angle,  immediately  behind  the 
septum  auricularum,  we  find  the  openings  of  the  right 
pulmonary  veins.  The  anterior  wall  looks  somewhat 
downwards;  it  corresponds  to  the  left  ventricle,  and 
presents  to  our  view  the  left  auriculo-ventricular  open- 
ing. The  superior  wall  looks  a  little  forward.  Lastly, 
the  inferior  wall  is  very  smooth,  and  forms  with  the  pos- 
terior wall  a  continuous  convex  surface  which  corre- 
sponds, with  the  interposition  of  the  pericardium,  to  the 
oesophagus  and  descending  aorta. 

The  left  pulmonary  artery  may  be  seen  crossing  from 
before  backwards,  so  as  to  get  behind  the  left  auricular 
appendix. 

In  order  to  see  the  interior  of  the  left  auricle,  an  in- 
cision should  be  made  vertically  through  its  posterior 
and  superior  walls,  so  as  to  separate  the  pulmonary  veins 
of  the  right  and  left  sides.  We  may  now  observe  that 
the  septum  of  the  auricles  is  convex  towards  the  left 
side ;  in  the  foetus  it  presents  the  valve  already  described 
in  connection  with  the  fossa  ovalis,  but  in  the  adult  it  is 
by  no  means  so  distinctly  marked.  The  auriculo-ven- 
tricular opening  situated  in  its  anterior  wall  is  smaller 
than  that  on  the  right  side,  and  its  long  axis  is  directed 
somewhat  transversely.  The  superior  portion  of  the 
left  wall  presents  the  orifice  of  the  auricular  aj^j^endix, 
which  is  smoother  internally  than  that  on  the  right 
side :  and  lastly,  opening  into  the  posterior  wall,  we 
observe  superiorly,  the  four  pulmonary  veins,  the  orifices 
of  which  are  unprovided  with  valves :  sometimes  the 
two  veins  of  the  left  side  have  a  common  opening ;  but 
when  there  are  four,  the  two  inferior  veins  have  the  larger 
openings,  and  the  two  left  veins  are  nearer  to  each  other 
than  the  two  right.  From  the  above  account  it  appears 
that  there  are  seven  openings  into  the  left  auricle  of  the 
foetus,  viz.,  the  four  openings  of  the  pulmonary  veins,  the 


o4  RIGHT  VENTRICLE. 

opening  of  the  left  auricular  appendix,  the  left  auriculo- 
ventricular  opening,  and  the  foramen  ovale.  There  are 
commonly  but  six  in  the  adult,  the  foramen  ovale  being 
ordinarily  closed :  a  small  valvular  opening,  however, 
occasionally  exists  in  the  adult  at  the  upper  part  of  the 
fossa  ovalis.  The  interior  of  this  auricle,  with  the  ex- 
ception of  its  appendix,  is  destitute  of  musculi  pectinati; 
it  is  therefore  smoother  than  the  interior  of  the  ri^ht 
auricle ;  it  is  also  stronger  in  its  muscular  structure,  and 
its  capacity  is  about  one-fifth  less. 

The  Eight  Yentricle  has  the  form  of  a  cone,  one  side 
of  which  has  been  hollowed  out  to  accommodate  the 
convexity  of  the  left  ventricle.  Its  apex  is  turned  in 
the  same  direction  as  the  apex  of  the  heart ;  but,  in  the 
adult,  does  not  extend  so  low.  Its  base  presents,  ante- 
riorly and  to  the  left  side,  a  funnel-shaped  pouch,  called 
the  infundibulum,  or  conus  arteriosus,  from  which  the 
pulmonary  artery  arises;  and,  posteriorly,  the  opening 
into  the  right  auricle:  between  these  two  openings  it 
corresponds  to  the  origin  of  the  aorta.  In  order  to  ex- 
pose its  interior,  an  incision  should  be  made  into  it,  in 
the  direction  of  the  axis  of  the  heart,  and  close  to  the 
septum  ventriculorum. 

The  internal  surface  of  the  right  ventricle  is  exceed- 
ingly rough,  from  the  development  of  a  number  of  mus- 
cular prominences,  termed  the  carnem  columnce :  of  these 
there  are  three  orders :  those  of  the  first  order  are 
attached  by  both  extremities  and  by  one  side  to  the 
ventricle;  those  of  the  second  are  attached  by  their 
two  extremities ;  and  those  of  the  third  order  are  at- 
tached by  only  one  extremity  to  the  ventricle,  the  other 
being  connected,  through  the  medium  of  tendinous 
chords  (chordce  tendineoe),  to  the  valves  of  the  auriculo- 
ventricular  opening.     The  two  first  are  supposed  to  be 


RIGHT   VENTRICLE.  35 

for  the  purpose  of  mixing  the  blood  more  completely ; 
but  those  of  the  third  order,  contracting  at  the  same 
time  with  the  ventricle,  prevent  the  blood  from  forcing 
back  the  valves  into  the  auricle.  That  portion  of  the 
interior  of  the  ventricle  which  forms  the  infundibulum, 
is  exceedingly  smooth,  in  order  to  facilitate  the  flow  of 
blood  into  the  pulmonary  artery;  and  it  will  be  observed, 
that  several  of  the  columns  of  the  first  and  second  orders 
have  one  of  their  extremities  attached  to  the  commence- 
ment of  that  portion  of  the  septum,  which  contributes 
to  form  the  infundibulum.  By  means  of  this  beautiful 
arrangement,  these  columns,  during  the  contraction  of 
the  ventricle,  draw  upon  this  portion  of  the  infundibu- 
lum, and  so,  by  maintaining  its  tension,  preserve  its 
smoothness  of  surface  for  the  passage  of  the  blood  into 
the  pulmonary  artery.  The  right  auriculo-ventricular 
opening  is  seen  at  the  base  of  the  ventricle,  posteriorly, 
and  about  an  inch  to  the  right  of  the  orifice  of  the  pul- 
monary artery :  it  is  circular  when  the  blood  is  passing 
through,  but  elliptical  at  other  times.  Surrounding  this 
opening  are  seen  three  triangular  folds  of  the  lining 
membrane  or  endocardium,  which  constitute  the  tricus- 
pid valve.  This  valve  consists,  as  its  name  implies,  of 
three  portions,  each  triangular;  the  base  attached  to 
the  zona  tendinosa,  surrounding  the  right  auriculo-ven- 
tricular aperture,  the  apex  connected  with  the  chordsB 
tendinese ;  the  anterior  portion  corresponds  to  the  ante- 
rior wall  of  the  right  ventricle;  the  posterior  corre- 
sponds to  the  septum  ventriculorum ;  and  the  left  di- 
vision looks  towards  the  opening  of  the  pulmonary 
artery :  this  last  is  the  largest  portion  of  the  valve,  and 
is  called  the  valvular  septum  of  JLieutaud  of  the  right  ven- 
tricle :  it  is  supposed  to  be  of  use  in  preventing  any  of 
the  blood  flowing  from  the  right  auricle,  from  getting 
directl}^  into  the  pulmonary  artery,  until  it  has  first  filled 


36  RIGHT   VENTRICLE. 

the  right  ventricle :  by  this  arrangement  the  blood  be- 
comes subject  to  the  entire  force  of  the  right  ventricle, 
in  order  to  its  propulsion  through  the  pulmonary  vessels. 
The  auricular  surface  of  the  tricuspid  valve  is  extremely 
smooth,  for  the  purpose  of  facilitating  the  flow  of  blood 
into  the  ventricle ;  whilst  the  surface  which  corresponds 
to  the  walls  of  the  ventricle  is  remarkably  rough,  from 
the  prominences  formed  by  the  chorda?  tendine^e.  To 
the  margins  of  the  valve  the  chordas  tendinese  are  at- 
tached, and  afterwards  become  spread  out,  interlacing 
with  each  other,  so  as  to  give  rise  to  a  strong  fibrous 
expansion  between  the  foldings  of  the  lining  membrane 
which  form  each  division  of  the  valve :  they  are  ulti- 
mately lost  by  becoming  continuous  with  the  zona  tendi- 
nosa  surrounding  the  base  of  the  ventricle.  The  tricuspid 
valve  prevents  the  blood  from  returning  into  the  auricle, 
when  the  ventricle  contracts  to  expel  it  into  the  pulmo- 
nary artery :  this,  however,  it  does  not  do  completely, 
as  a  certain  amount  of  regurgitation  is  permitted  into 
the  right  auricle  at  this  particular  moment,  in  the  healthy 
condition  of  the  parts.  In  1792,  John  Hunter  writes, 
"  I  have  reason  to  believe  that  the  valves  in  the  right 
side  of  the  heart,  do  not  so  jDcrfectly  do  their  duty,  as 
those  of  the  left ;  therefore,  we  may  suppose  it  was  not 
so  necessary."*  Many  years  back,  Mr.  Adams  saw  the 
force  of  Hunter's  observation,  and  fully  aj^preciated  its 
importance.  In  his  original  and  admirable  paper  on 
Diseases  of  the  Heart,  published  in  1827,  when  speaking 
of  the  fact  alluded  to  by  Hunter,  he  observes,  "This 
circumstance,  in  my  opinion,  has  not  been  sufficiently 
noticed,  nor  the  influence  that  such  a  structure  may 
have  on  the  circulation  in  its  natural,  or  morbid  state, 
considered. — Such  a  provision  was  absolutely  necessary 

*•  ''Treatise  on  the  Blood,"  &c.  page  177. 


RIGHT   VENTRICLE.  37 

in  the  right  or  pulmonary  ventricle,  as  various  natural 
causes  must  momentarily  retard  the  passage  of  blood 
through  the  lungs.  In  the  natural  state  of  the  heart, 
it  is  j^robable  that  there  is  constantly  some  little  reflux 
into  the  right  auricle,  during  the  contraction  of  its  cor- 
responding ventricle,  as  the  valves  readily  admit  it ;  but 
the  great  swelling  of  the  jugular  veins  is  only  seen  when 
extraordinary  efforts  are  made,  or  when,  from  any  en- 
largement of  the  right  side  of  the  heart,  it  is  capable  of 
containing  a  larger  quantity  of  blood  than  it  can  readily 
transmit  through  the  lungs,  or  the  left  receive ;  on  these 
occasions  it  is,  that  the  pulsations  in  the  jugular  veins 
become  evident ;  they  are  synchronous  with  the  action 
of  the  heart.  Upon  the  whole,  therefore,  I  would  con- 
clude, that  the  pulsation  in  the  jugular  veins,  viewed  as 
a  symptom  of  the  disease  we  have  been  just  considering 
(contraction  of  the  left  auriculo-ventricular  .  opening), 
depends  upon  this,  that  the  right  ventricle,  unable  to 
transmit  all  the  blood  which  distends  it,  through  the 
pulmonary  artery,  part  of  it  must  regurgitate  towards 
the  auricle,  and  displace  a  column  of  blood  descending 
into  this  cavity  from  the  jugular  veins,  causing  thus  a 
momentary  reflux  or  pulse  in  the  veins  nearest  the  right 
auricle."*  In  the  second  volume  of  the  Guy's  Hospital 
Eeports,  1837,  Mr.  King  pubhshed  "An  Essay  on  the 
Safety-valve  Function  of  the  Human  Heart,"  &c.,  and 
adverts  to  the  fact  stated  by  John  Hunter.  Mr.  King 
calls  the  septum  of  the  ventricles  the  solid  wall  of  the 
right  ventricle;  and  its  anterior,  he  calls  the  yielding 
wall.  Between  these  two  walls  he  describes  a  muscular 
band  as  stretching  across  the  area  of  the  right  ventricle ; 
he  calls  this  the  moderator  hand,  and  believes  it  to  be  of 


*  "  Cases  of  Diseases  of  the  Heart,"  &c.,  in  4th  vol.  of  Dublin  Hospital 
Reports,  pp.  437-438. 

4 


38 


RIGHT    VENTRICLE. 


Pig.\.—Tliis  figure  represents  the  anterior  part  of  the  Right  Ventricle  and  Pulmo- 
nary Artery  laid  open  and  turned  npioards. 


A.  Superior  Vena  Cava.  B.  The  Aorta.  C,  The  Semilunar  Valves  of  P"^™''"?;'^  Artery.  D,  The 
PulAionary  Artery.  E,  Remains  of  the  Ductus  Arteriosus.  F,  Right  Auricle,  ^^x- Tr>cui>Pia  Va  ve. 
H  PorUou  of  Right  Auriculo-Ventricular  Opening.  I,  Fleshy  Column  connected  with  the  Septum  of 
the  Ventricles  by  one  extremity,  nnd  with  the  Valvular  Septum  of  I>icutaudl.y^he  other     K   Part  of 


Left  Auricle.    M,  Carneae  Columnaj  attached  to  the   Chordae   TendineK. 
tricle.    O,  Septum  Veutriculorum. 


N,  Cavity  of  Right  Vcn- 


LEFT   VENTRICLE.  39 

use  in  limiting  distention  of  this  cavity.  Of  the  three 
divisions  of  the  tricus2:)id  valve,  he  describes  two,  viz., 
what  he  calls  the  anterior  curtain  and  the  right  curtain, 
as  being  attached  to  the  flesh}"  columns  which  are  fixed 
in  the  yielding  wall.  From  this  mechanism  he  con- 
cludes, that  when  from  sudden  repletion,  exertion,  ex- 
posure to  cold,  or  impeded  respiration,  a  distention  occurs 
in  the  great  veins  and  right  side  of  the  heart,  the  yield- 
ing wall  will  carry  the  valves  partly  away  from  one  an- 
other, and  by  such  separation  will  prevent  the  injurious 
effects  of  over-distention,  by  producing  the  necessary 
amount  of  regurgitation  from  the  right  ventricle  into 
the  right  auricle  and  great  veins.  To  this  valvular 
apparatus,  which  guards  the  right  auriculo-ventricular 
opening,  Mr.  King  gives  the  name  of  the  "safety-valve." 
By  the  "tendinous  zone"  is  meant  the  whitish  ring 
that  binds  the  auriculo-ventricular  opening:  as  there 
is  a  similar  one  on  the  left  side,  we  shall  consider  both 
at  the  same  time. 

The  Left  Yentricle.  This  cavity  also  is  of  a  conical 
form :  its  ajjex  constitutes,  in  the  adult,  the  apex  of  the 
heart :  and  its  base  has  an  arterial,  and  an  auricular 
opening.  The  interior  of  the  left  ventricle  may  be 
exposed  by  an  incision  similar  to  that  recommended 
when  speaking  of  the  right :  the  arterial  opening  thus 
exposed,  will  be  found  in  front  of  the  auriculo-ventricu- 
lar aperture,  and  a  little  to  its  right  side.  The  auriculo- 
ventricular  opening  is  guarded  by  two  triangular  folds 
of  the  lining  membrane,  which  constitute  the  mitral 
valve  of  Yesalius.  The  anterior  lamina  of  this  valve  is 
much  larger  than  the  posterior,  and  has  been  correctly 
termed  the  valvular  septum  of  Lieutaud  of  the  left  ven- 
tricle ;  that  anatomist  supposed  that  it  was  applied 
against  the  orifice  of  the  aorta  while  the  ventricle  was 


40  ZON^   TENDINGS^. 

filling :  this  appears  possible,  as  the  aortic  opening  is  in 
front  of  the  auriculo-ventricular,  and  the  substance  of 
this  valve  separates  the  two  openings  from  each  other. 
The  mitral  valve  is  similar  in  structure  to  the  tricuspid  : 
it  does  not,  however,  admit  of  regurgitation  of  the  blood 
from  the  left  ventricle  into  the  left  auricle;  and  the  two 
surfaces  of  the  anterior  division  of  the  valve  are  equally 
smooth; — the  posterior  surface  for  the  purj^ose  of  facili- 
tating the  flow  of  blood  from  the  auricle  into  the  ven- 
tricle ;  and  the  anterior,  the  flow  from  the  ventricle  into 
the  aorta.  In  this  respect  this  portion  of  the  valve  differs 
from  the  posterior,  and  from  the  three  portions  of  the 
tricuspid  valve.  The  muscular  structure  of  this  ven- 
tricle is  much  thicker  and  stronger  than  that  of  the 
right  ventricle. 

The  zonce  tendinosce  of  the  heart  are  four  in  number ; 
one  is  situated  at  the  narrow  portion  of  the  infundibu- 
lum  of  the  right  ventricle,  and  gives  attachment  to  the 
origin  of  the  pulmonary  artery  :  the  second  is  placed  at 
that  part  of  the  left  ventricle  from  which  the  aorta  takes 
its  origin;  these  may  be  called  the  two  arterial  zones. 
The  remaining  two  may  be  termed  the  auriculo-ventricu- 
lar zones  ;  they  mark  the  connection  between  the  auricles 
and  ventricles,  surround  the  auriculo-ventricular  ori- 
fices, and  give  attachment  to  the  bases  of  the  tricuspid 
and  mitral  valves:  they  are  composed  of  pale,  con- 
densed, tendinous  fibres;  they  have  the  same  form  as 
the  auriculo-ventricular  openings,  which  they  surround; 
and  they  receive  and  are  continuous  wnth  those  ex- 
pansions of  the  chordae  tendinese,  w^hich  are  placed 
between  the  laminae  of  the  endocardium  composing  the 
mitral  and  tricusjiid  valves,  and  which  thus  add  consi- 
derably to  their  strength.  These  zones  may  be  best 
seen  by  dissecting  from  the  interior  of  the  heart.  The 
endocardium,  or  lining  membrane,  is  in  intimate  con- 


bouillaud's  opinions.  41 

nection  with  the  inner  surftxce  of  these  zones,  and  is 
thicker  here  than  in  other  situations. 

According  to  JBouillaud,  the  cavity  of  each  ventricle 
is  composed  of  two  very  distinct  regions,  one  communi- 
cating with  the  corresponding  auricle,  and  the  other 
with  the  artery  arising  from  its  base;  and  these  two 
portions  are  not  constituted  exactly  alike  in  the  right 
and  left  sides.  In  the  7ight  ventricle,  the  arterial  portion 
is  united  with  the  auricular  portion,  by  means  of  an 
angle  projecting  into  the  ventricle,  the  sinus  of  which  is 
consequently  turned  upwards,  embracing  the  aorta.  In 
the  left  ventricle,  the  arterial  and  auricular  regions  are 
very  nearl}^  parallel  to  each  other,  so  that  their  axes 
approach  one  another  as  they  proceed  from  the  base  to 
the  apex  of  this  cavity  :  they  are  separated  by  the  ante- 
rior lamina  of  the  mitral  valve,  and  by  two  large  fleshy 
columns,  which  are  inserted  into  it  by  means  of  nume- 
rous tendons.  Inferior,  posterior,  and  a  little  to  the 
left  of  this  septum,  is  the  auricular  region  of  the  ven- 
tricle ;  and  superior,  anterior,  and  internal  to  it,  is  the 
arterial  or  aortic  portion.  These  two  regions  communi- 
cate with  each  other  freely  at  the  interval  between  the 
two  large  columns  above  mentioned.  It  is  in  the  auri- 
cular region  of  the  ventricle  that  we  principally  find  the 
fleshy  columns  -,  in  fact,  a  large  portion  of  the  arterial 
region  is  altogether  destitute  of  them;  and  the  same 
remark  will  apply  to  the  right  ventricle  :  those  that  are 
found  in  the  arterial  region  are  small  and  interlaced, 
and  are  not,  like  the  large  ones,  inserted  into  the  valves. 
The  left  ventricle  contains  fewer  carneae  columnae  than 
the  right;  they  are,  however,  more  voluminous. 

Relative  capacities  of  the  Cavities.  Each  of  the  four 
cavities  of  the  heart  is  capable  of  containing  about  two 
ounces  of  blood.  The  ventricles  are  suj)posed  to  contain 
a  little  more  than  the  auricles.     The  right  auricle  and 

4-» 


42 


LEFT  VENTRICLE  AND  AORTA. 


Fig.  ^.— This  figure  represents  the  Interior  of  Left  Ventricle  and  Aorta  laid  open 
by  dissecting  from  before  backwards. 


A  Aorta  B  C  Left  Pulmonary  Veins.  D,  D,  Orifices  of  the  Coronary  Arteries,  E,  Interior  of 
Left  Auricle.  P,  P,  Semilunar  Valves  of  the  Aorta.  G,  Anterior  Surface  of  the  A'alvular  Septum 
of  Lieutaud,  and  passage  from  the  Cavity  of  the  Ventricle  into  the  Aorta.  H,  Attachment  of  Chordae 
Teudinea;  to  the  Mitral  Valve.  I.  Left  Auriculo- Ventricular  Opening.  J,  Carncae  Columnae.  K, 
Lower  Portion  of  the  Cavitv.  L,  Eight  Auricular  Appendix.  M,  Carnea;  Column*.  N,  Right  ^en- 
tricle.    O,  Septum  Ventriculorum  dissected,  and  cut  surface  shown. 


STRUCTURE   OF   THE    HEART.  43 

right  ventricle  are  somewhat  larger  in  their  capacities 
than  the  cavities  of  the  left  side ;  anatomists  are  not, 
however,  fully  agreed  upon  this  point. 

The  weight  of  the  heart  is  estimated  at  about  from 
eight  to  ten  ounces. 

STRUCTURE   OF   THE   HEART. 

The  heart  is  essentially  composed  of  muscular  fibres, 
covered  on  the  outside  by  the  serous  layer  of  the  peri- 
cardium, and  on  the  inside  by  the  endocardium,  which 
is  continuous  with  the  lining  membrane  of  the  arteries 
and  veins.  It  has  been  ascertained  by  Miiller,  that  the 
primitive  fasciculi  of  the  muscular  structure  of  the 
heart,  present  the  transverse  stria)  or  crosi^  markings 
which  are  seen  upon  the  primitive  fibres  of  the  volun- 
tary muscles.  Todd  and  Bowman  state,  that  "the 
cross  stripes  on  the  fibres  of  the  heart  are  not  usually 
so  regular  or  distinct,  as  in  those  of  the  voluntary 
muscles.  They  are  often  interrupted,  or  even  not 
visible  at  all.  The  fibres  are  usually  smaller  than  the 
average  diameter  of  those  of  the  voluntary  muscles  of 
the  same  subject,  by  two-thirds,  as  stated  by  Mr.  Skey; 
and  in  most  parts  of  the  parietes  of  this  viscus,  they  are 
not  aggregate  in  parallel  sets,  but  twine  and  change 
their  relative  positions."*  Entering  into  the  composi- 
tion of  the  heart,  we  find  also  tendons,  arteries,  veins, 
nerves,  and  absorbents :  it  is  said  to  possess  little  or  no 
areolar  tissue. 

The  muscular  fibres  of  the  heart  may  be  traced,  first  in 
the  ventricles,  and  afterwards  in  the  auricles.  In  order 
to  prepare  the  heart  for  the  examination  of  these  fibres, 

*  Physiological  Anatomy,  vol.  i.  p.  161. 


44  MUSCULAR   FIBRES   OF   THE    HEART. 

it  should  be  hardened  by  maceration  in  alcohol,  or  by 
boiling:  its  external  and  internal  membranes  may  be 
then  cautiously  raised,  and  the  different  layers  of  mus- 
cular fibres  examined,  commencing  with  those  most  in- 
ternal, and  following  carefully  the  course  of  the  fibres. 

First: — in  each  of  the  ventricles  wo  find  a  proper  set 
of  fibres  arranged  so  as  to  form  a  small  conical  sac, 
open  at  both  extremities,  the  inferior  opening  being 
much  the  smaller:  these  may  be  termed  ventricular  sacs. 
In  addition  to  the  proper  fibres,  the  ventricles  have 
also  a  common  set,  which  cover  and  unite  the  proper 
ones,  and  inferiorly  at  the  apex  of  the  heart  become  in- 
flected and  penetrate  the  small  apertures  above  men- 
tioned, in  the  ventricular  sacs,  on  the  internal  surface 
of  which  they  are  expanded.  They  have  been  repre- 
sented as  forming  six  sets  of  layers  in  the  left  ventricle, 
and  three  in  the  right;  the  fibres  do  not  confine  them- 
selves to  particular  planes;  but  the  planes  mutually 
penetrate  each  other,  and  are  moreover  united  by  fibres 
reciprocally  detached  from  one  to  the  other.  The  super- 
ficial fibres  proceed  spirally  from  the  base  to  the  apex; 
those  on  the  anterior  surface  incline  from  right  to  left, 
and  those  on  the  posterior  surface  from  left  to  right. 
Having  arrived  at  the  apex  of  the  heart,  they  are  in- 
flected, as  already  observed,  towards  its  interior,  and 
therefore  present  in  this  situation,  when  the  pericardium 
has  been  carefully  dissected  off,  the  appearance  of  a  star, 
the  rays  of  which  are  not  straight,  but  curved.  The  in- 
flected superficial  fibres  enter  the  openings  in  the  ven- 
tricular sacs,  and  therefore  both  ventricles  may  be  pene- 
trated at  the  apex  of  the  heart,  without  dividing  the 
fibres.  In  the  interior  of  the  ventricles,  some  of  the  in- 
flected fibres  ascend  from  the  apex  on  the  interior  of 
the  same  wall  upon  which  they  had  descended  in  pass- 
ing downwards  from  the  base;  others  ascend  on  the 


MUSCULAR   FIBRES   OF   THE   HEART.  45 

Opposite  wall;  and  a  third  set  terminate  in  the  carncsB 
columna3.  Secondly : — in  each  of  the  auricles  the  proper 
fibres  arise  from  the  tendinous  zones :  on  the  left  side 
some  of  them  assume  a  circular  arrangement  in  the 
vicinity  of  the  auriculo-ventricular  openings,  and  nume- 
rous oblique  bands  proceed  from  the  same  origin  in 
various  directions:  one  passes  between  the  appendix 
and  left  pulmonary  veins;  another  fills  the  interval  be- 
tween the  pulmonary  veins  of  the  right  and  left  sides, 
and  others  between  the  pulmonary  veins  of  the  same 
side,  forming  a  border  for  their  orifices;  independently 
of  which,  the  orifices  seem  specially  provided  with  proper 
sphincters.  On  the  right  side,  the  part  of  the  auricle 
corresponding  to  the  junction  of  the  superior  and  in- 
ferior cav89  has  no  muscular  fibres  except  a  small  band 
on  the  right  side  of  the  orifice  of  the  superior  cava. 

In  the  rest  of  the  auricle  we  distinguish  two  principal 
muscular  bands:  one  embracing,  in  a  circular  manner, 
the  right  auriculo-ventricular  opening;  and  the  other 
descending  from  the  interval  between  the  right  auri- 
cular a2)pendix  and  superior  cava,  to  terminate  on  the 
right  side  of  the  inferior  cava.  Between  these  two 
bands  the  muscular  fibres  are  arranged  in  a  fasciculated 
manner,  constituting  the  musculi  pectinati. 

The  superficial  fibres  of  the  auricles  constitute  a  thin 
layer  passing  transversely  from  one  auricle  to  another, 
and  arising  from,  and  terminating  in,  the  tendinous 
zones. 

From  the  above  account,  it  follows  that  the  right 
and  left  sides  of  the  heart  may  be  separated  from  each 
other  by  the  division  of  the  common  fibres,  leaving  the 
proper  fibres  uninjured.  For  this  purpose  an  incision 
should  be  made  with  caution  through  the  anterior 
fibres  of  the  ventricles  parallel  to  the  anterior  fissure 
of  the  heart,  and  then  the  right  and  left  sacs,  above 


46  MUSCULAR   FIBRES    OF   THE    HEART. 

described,   constituted   by  the   proper   fibres,   may  be 
separated  with  the  finger.     In  order  to  separate  the 
auricles,  the  incision  should  be  made  parallel  to  their 
posterior  median  fissure,  and  still   greater  caution  is 
necessary  here  than  in  the  separation  of  the  ventricles. 
The  ventricular  sacs  have  been  described  as  having  a 
conical  form :  this  is  strictly  true,  more  particularly  of 
the  left  side,  all  parts  of  the  exterior  of  the  left  sac 
being  convex;  but  on  the  right  side  the  part  of  the  sac 
which  is  aj^plied  to  the  left  ventricle  is  concave.     Now, 
the  reverse  occurs  in  the  auricles,  the  right  presenting  a 
convexity  which  is  received  into  the  concavity  of  the  left. 
Mr.  Searle  remarks,  that  "the  fibres  of  the  heart  are 
not  connected  together  by  cellular  tissue,  as  are  those  of 
other  muscles,  but  by  an  interlacement  which  in  some 
parts  is  very  intricate,  and  in  others  scarcely  perceptible. 
At  the  entire  boundary  of  the  right  ventricle  they  de- 
cussate, and   become  greatly  intermixed;  at  the   apex 
and  base  of  the  left  ventricle  they  twist  sharply  round 
each  other,  and  so  become  strongly  embraced;  but  in 
general  the  interlacement  is  so  slight  that  they  appear 
to  run  in  parallel  lines.     Whether  a  mere  fasciculus,  or 
a  considerable   mass  of  this  last  description  of  fibres, 
be  split  in  the  direction  of  the  fibres,  a  number  of  deli- 
cate parallel  fibres  will  present  themselves,  some  being 
stretched  across  the  bottom  of  the  fissures,  perfectly 
clean  and  free  from  any  connecting  medium  w^hatever; 
and   although   some   must   necessarily  be   broken,  yet 
these  are  so  few  that  they  do  not  attract   attention 
unless  sought  for.     The  disposition  of  the  fibres  varies 
in  different  parts  of  the  heart,  forming  parallel  lines, 
angles,  decussations,  flat  and  spiral  twists.     The  fibres 
are   arranged   in  fasciculi,  bands,  layers,  and  a  rope, 
which  are  so  entwined  together  as  to  form  the  two 
chambers  called  the  right  and  left  ventricles.    These  are 


iMUSCULAR    riBRES    OF    THE    HEART.  47 

lined  with  their  internal  proper  membrane.  The  fasci- 
culi contribute  to  the  formation  of  the  bands.  By 
tracing  the  fibres  in  bands,  we  are  enabled  to  develop 
the  formation  of  the  ventricles  in  a  progressive  and  sys- 
tematic manner.  The  bands  spring  from  a  mass  of  fibres 
which  forms  the  apicial  part  (the  apex)  of  the  left  ven- 
tricle, and  which  in  winding  round,  just  above  the  apex 
of  the  heart,  separates  into  two  bands  to  form  the  right 
ventricle.  The  average  width  of  the  bands  is  not  less 
than  a  third  of  the  extent  between  the  apex  and  base 
of  the  left  ventricle.  A  considerable  mass  of  fibres  may 
be  exposed  winding  just  above  the  apex;  at  the  sej^tum 
it  splits  into  two  bands :  the  one,  a  ^  short  band/  encircles 
spirally  both  ventricles,  one  half  round  the  right,  the 
other  half  round  the  left  ventricle.  The  second,  or 
^longer  band,'  describes  two  circles:  it  first  ]3asses 
through  the  septum,  and  round  the  left  ventricle;  it 
secondly  passes  round  the  base,  and  includes  both  ven- 
tricles in  its  circuit.  "  The  fibres  of  this  band,  in  form- 
ing the  brim  of  the  left  ventricle,  make  a  sharp  twist 
like  those  of  a  ^rope/  by  w^hich  means  they  become  the 
inner  fibres  of  this  chamber,  and  expand  into  a  layer 
which  enters  largel}^  into  the  formation  of  that  mass 
which  has  already  been  described  as  forming  the  apex 
of  the  left  ventricle  and  dividing  into  the  two  bands. 
Thus  the  principal  band,  although  it  receives  several  in- 
crements-of  fibres,  has  no  complete  beginning  nor  end- 
ing, a  considerable  portion  of  it  originating  and  termi- 
nating in  itself 

"  The  septum  of  the  ventricles  is  composed  of  three 
layers;  a  left,  a  middle,  and  a  right  layer.  The  two 
former  properly  belong  to  the  left  ventricle;  and  the 
last,  or  right  layer,  exclusively  pertains  to  the  right  ven- 
tricle. The  two  former  are  composed  of  the  primitive 
mass  of  fibres  derived  from  the  '  rope'  already  alluded 


48  THE   ENDOCARDIUM. 

to  as  forming  the  brim  of  the  left  ventricle,  and  the 
carne83  columnae  of  the  same  ventricle.  The  last,  or 
right  layer  of  the  septum,  has  not  the  same  origin  as 
the  two  former  have ;  its  fibres  arise  from  the  root  and 
lower  margin  of  the  valve  of  that  section  of  the  aorta 
which  pertains  to  the  right  ventricle,  from  that  part  of 
the  root  of  the  pulmonary  artery  contiguous  to  the  aorta, 
and  from  the  carneae  columnse  of  the  right  surface  of  the 
septum." 

"  It  appears  from  the  patient  and  laborious  investiga- 
tions of  Mr.  Searle,  that  the  great  mass  of  the  fibres  of 
the  heart  are  arranged  in  a  spiral  direction ;  that  many 
of  them  take  a  single  curve,  so  as  to  surround  both  ven- 
tricles; that  others  dip  into  the  septum  and  form  a 
double  curve,  one  surrounding  the  right  ventricle,  the 
other  the  left;  whilst  several  others  penetrate  from  the 
exterior  into  the  apex,  and  become  continuous  with  the 
carnea3  columnsB  in  the  interior  of  the  ventricles.''  * 

The  spiral  course  taken  by  the  fibres  of  the  ventricles, 
and  the  continuity  of  the  external  with  the  internal 
fibres  of  these  cavities,  were  known  long  ago  to  Winslow, 
Lancisi,  Lower,  and  Gerdy. 

THE   ENDOCARDIUM. 

This  is  a  transparent  membrane,  much  more  delicate 
than  the  serous  membranes,  which,  how^ever,  it  strongly 
resembles.  Its  free  surface  is  highly  polished  and  glis- 
tening; its  attached  surface  is  united  to  the  subjacent 
tendinous  and  muscular  structures  by  very  fine  areolar 
tissue,  which  is  often  found  thickened  and  altered  by 
disease,  particularly  at  the  left  side.  The  endocardium 
is  thicker  in  the  left  cavities  of  the  heart  than  in  the 
right,  and  thickest  opposite  the  auriculo-ventricular  and 

*  Todd's  Cyclopaedia,  p.  619. 


ARTERIES   OF   THE    HEART.  49 

arterial  orifices,  in  which  situations  it  is  often  found 
morbidly  thick  and  rough,  in  consequence  of  chronic  in- 
flammation. It  consists  of  a  layer  of  epithelium  placed 
on  a  stratum  of  fine  fibres,  which  exhibit  minute  vvavings. 
The  epithelium  appears  to  be  extremely  delicate,  but  the 
same  in  all  its  characters  as  that  of  the  blood-vessels. 
It  is  so  delicate,  that  to  be  seen  satisfactorily  it  must  be 
examined  in  animals  just  killed.  We  observe  two  forms 
of  epithelial  particles:  one  soft,  rounded,  and  globular; 
the  other  somewhat  compressed  and  drawn  out  at  oppo- 
site poles  into  pointed  or  fibre-like  processes.  It  is  diffi- 
cult to  determine  the  precise  relative  position  of  these 
two  forms  of  epithelium ;  but  it  seems  probable  that  the 
pointed  processes  are  the  more  deeply  seated,  and  are  in 
immediate  contact  with  the  subjacent  fibrous  layer,  which 
here  corresponds  to  the  basement  membrane  beneath  the 
epithelium  of  serous  and  mucous  membranes.* 

The  Arteries  of  the  heart  are  two  in  number,  viz.,  the 
posterior  and  anterior  coronary. 

The  posterior,  or  right  coronary  artery,  arises  from  the 
aorta,  above  the  margin  of  one  of  the  semilunar  valves; 
and  after  communicating  with  the  left  coronary  behind 
the  pulmonary  artery,  proceeds  outwards  in  the  groove 
between  the  right  auricle  and  right  ventricle.  Having 
reached  the  inferior  surface  of  the  heart,  it  divides  into 
two  branches;  owe  of  which  continues  in  the  same  groove, 
and  winding  around  the  base  of  the  heart,  anastomoses 
with  the  left  coronary  artery;  it  suppHes  the  right  auricle 
and  ventricle :  the  second,  from  its  size,  appears  the  con- 
tinued trunk :  it  descends  in  the  groove  on  the  posterior 
inferior  surface  of  the  heart,  accompanied  by  the  pos- 
terior coronary  vein,  along  the  septum  ventriculorum, 


*  Todd  and  Bowman's  Physiological  Anatomy,  vol.  11.  p.  335. 
5 


50  VEINS    OF    THE    HEART. 

supplies  both  ventricles,  and  near  the  apex  of  the  heart 
anastomoses  with  the  left  coronary.  The  branches  of 
the  right  coronary,  before  its  division,  are  the  following: 
first,  auricular  branches,  five  or  six  in  number,  which 
suj)ply  the  right  auricle,  the  septum  auricularum,  and 
the  parietes  of  the  venae  cavse;  secondly,  ventricular 
branches,  much  larger,  which  are  distributed  to  the  right 
ventricle ;  some  of  these  descend  on  the  superior  surface 
of  the  heart,  others  on  the  inferior,  and  one  along  its 
right  or  thin  margin. 

The  anterior y  or  left  coronary  artery,  smaller  than  the 
right,  arises  from  the  aorta,  above  the  margin  of  one  of 
the  semilunar  valves ;  it  then  proceeds  to  the  left,  till  it 
escapes  from  beneath  the  pulmonary  artery  and  divides 
into  a  superior  and  inferior  branch.  The  superior  winds 
round  the  base  of  the  heart  in  the  groove  between  the 
left  auricle  and  left  ventricle,  concealed  by  the  coronary 
vein,  and  anastomoses  with  the  right  coronary  artery : 
in  this  course  its  branches  are  distributed  principally  to 
the  left  ventricle;  others  go  to  the  left  auricle  and  the 
pulmonary  veins.  The  inferior  branch  is  the  larger;  it 
descends  on  the  anterior  superior  surface  of  the  heart, 
accompanied  by  the  anterior  coronary  vein,  in  the  groove 
between  the  two  ventricles.  Its  first  branches  ramify 
on  the  commencement  of  the  aorta  and  pulmonary 
artery;  the  rest  are  distributed  to  the  ventricles,  prin- 
cipally to  the  left. 

The  Veins  of  the  heart  are  the  greater  and  lesser  coro- 
nary :  the  greater  coronary  vein  commences  at  the  apex 
of  the  heart,  and  ascends,  under  the  name  of  the  anterior 
coronary  vein,  through  the  anterior  fissure,  gradually 
increasing  in  size :  having  arrived  at  the  base  of  the 
ventricles,  it  quits  the  coronarj-  artery,  and  turns  off  at 


VEINS    OF   THE    HEART.  51 

a  right  angle  to  the  left  side.  In  this  manner  it  gets 
into  the  groove  which  separates  the  left  auricle  from  the 
left  ventricle,  and  having  thus  arrived  at  the  inferior 
surface  of  the  heart,  it  opens  into  the  posterior  inferior 
part  of  the  right  auricle,  as  already  described.  Imme- 
diately before  its  termination,  this  vein  presents  a  re- 
markable ampulla  or  dilatation.  In  the  ascending  part 
of  its  course  it  receives  branches  from  the  septum 
ventriculorum,  and  from  the  right  and  left  ventricles ; 
and  during  its  transverse  direction  it  receives  descending 
branches  from  the  auricle,  and  ascending  and  larger 
branches  from  the  ventricle,  one  of  which  runs  along  the 
left  margin  of  the  heart.  In  its  ampulla  we  usually 
find  terminating,  the  posterior  coronary  vein  that  ascends 
through  the  posterior  inter-ventricular  fissure,  and  an- 
other that  crosses  from  right  to  left  between  the  right 
auricle  and  right  ventricle.  This  vein  has  no  valves, 
except  the  lesser  Eustachian  valve,  already  described  as 
situated  at  its  opening  into  the  right  auricle. 

The  lesser  coronary  veins  open  separately  into  the 
inferior  part  of  the  right  auricle  :  among  them  we  need 
only  notice  a  small  one  that  descends  from  the  infun- 
dibulum  of  the  right  ventricle,  and  another  the  vena 
Galeyii,  which  ascends  along  the  anterior  margin  of  the 
heart. 

The  coronary  vein  has  been  seen  to  enter  into  the  left 
auricle;*  and  Lecat  relates  a  case  in  which  it  opened 
into  the  left  subclavian  vein."}* 

The  Nerves  of  the  heart  are  principally  derived  from 
the  cervical  ganglia  of  the  sympathetic  nerve;  the  re- 
mainder proceed  from  the  pneumogastric  and  recurrent 


"•••  Jeflfray  on  the  Foetal  Heart. 

f  Mem.  de  I'Acad.  des  Sciences,  1738. 


52  NERVES    OP   THE    HEART. 

nerves :  they  are  distributed  in  greater  number  on  the 
right  side  than  on  the  left. 

The  Cardiac  nerves,  derived  from  these  sources,  con- 
verge from  both  sides  upon  the  origin  of  the  aorta  and 
puhnonary  artery,  and  form  the  cardiac  plexuses,  which, 
dividing  into  the  right  and  left  coronary  j)lexuses,  sur- 
round and  accompany  the  coronary  arteries  and  their 
branches. 

There  are  three  principal  cardiac  nerves  derived  from 
the  sympathetic  on  each  side,  viz.,  the  superior  or  super- 
ficial cardiac,  the  middle  or  deep  cardiac^  and  the  inferior 
or  small  cardiac  nerves. 

The  Superior  cardiac  nerve  arises  from  the  superior 
cervical  ganglion  of  the  sympathetic,  or  from  the  com- 
municating branch  which  connects  this  ganglion  with 
the  middle;  it  is  joined  by  one  or  two  filaments  from  the 
pneumogastric  nerve. 

The  Middle  cardiac  nerve  arises  from  the  middle  cer- 
vical ganglion;  but  when  this  ganglion  is  absent,  the 
nerve  arises  from  the  trunk  of  the  sympathetic  itself. 
Scarpa  has  called  this  the  great  cardiac  nerve,  from  its 
frequently  being  the  largest  of  the  three :  sometimes, 
however,  it  is  absent  altogether. 

The  Inferior  cardiac  nerve,  called  also  the  cardiacus 
minor,  usually  arises  from  the  inferior  cervical  ganglion, 
very  often  from  the  first  thoracic  ganglion.  The  middle 
and  inferior  cardiac  nerves  communicate  freely  with 
branches  from  the  recurrent. 

There  are  some  differences  between  the  cardiac 
branches  of  the  right  and  left  sides :  viz.,  the  middle 
cardiac  nerve  of  the  left  side  receives  its  principal 
branch  from  the  inferior  cervical  ganglion;  and  very 
frequently  on  this  side  the  middle  and  inferior  cardiac 
nerves  are  united  into  a  single  trunk.  The  cardiac 
branches  of  the  pneumogastric  nerve  of  the  right  side 


NERVES   OF   THE   HEART.  53 

are  usually  three  or  four  in  number,  and  arise  from  their 
parent  trunk  about  an  inch  above  the  origin  of  the  com- 
mon carotid  artery;  they  are  lost  in  the  cardiac  fila- 
ments of  the  inferior  cervical  ganglion.  The  pneumo- 
gastric  nerve  of  the  left  side  generally  sends  off  only  a 
single  twig,  which  runs  on  the  front  of  the  arch  of  the 
aorta  and  enters  the  neighboring  cardiac  plexus. 

The  cardiac  plexuses  are  three  in  number, — the  greatj 
the  superficial  or  anterior,  and  the  deep  or  posterior.  The 
first  is  seen  in  front  of  the  trachea  and  above  the  right 
pulmonary  artery,  and  behind  the  arch  of  the  aorta  j 
it  is  formed  principally  by  the  middle  and  inferior  car- 
diac nerves  of  both  sides.  The  second  is  situated  upon 
the  front  of  the  aorta,  close  to  its  origin,  and  may  be 
exposed  by  removing  the  serous  layer  of  the  pericar- 
dium from  this  vessel :  branches  from  the  great  cardiac 
plexus,  from  the  superior  cardiac  nerves,  and  from  the 
cardiac  ganglion,  enter  this  plexus.  The  third  is  situated 
immediately  behind  the  origin  of  the  aorta. 

The  cardiac  ganglion  of  Wrisberg,  when  present,  is 
situated  underneath  the  arch  of  the  aorta,  and  is  in 
contact  with  that  part  of  the  concavity  of  the  artery 
which  lies  to  the  right  side  of  its  connection  with  the 
ductus  arteriosus :  the  superior  cardiac  nerves  of  the 
right  and  left  sides,  together  Avith  filaments  from  the 
pneumogastric  nerves,  enter  into  its  formation.  The 
cardiac  branches  of  the  recurrent  nerve  are  pretty 
numerous,  and  unite  with  the  cardiac  branches  of  the 
pneumogastric  and  great  sympathetic. 

The  anterior  and  posterior  coronary  plexuses  are 
branches  derived  from  the  cardiac  plexuses,  which 
accompany  the  coronary  arteries  and  their  branches. 

The  Lymphatics  of  the  heart  consist  of  a  superficial 
and  a  deep  set :  the  superficial  set  form  a  net- work  under 
the  serous  layer  of  the  pericardium ;  the  deep  set  ramify 

6* 


54  PULMONARY   ARTERY. 

between  the  endocardium  and  muscular  fibres ;  and  both 
of  them  follow  the  coronary  vessels.  Some  of  them 
unite  with  the  lymphatics  of  the  lung,  and  others  ter- 
minate in  the  lymphatic  glands  in  front  of  the  arch  of 
the  aorta  and  pulmonary  veins. 

THE   PULMONARY   ARTERY. 

This  vessel  may  be  easily  injected  from  the  superior 
or  inferior  vena  cava.  It  arises  from  the  infundibulum 
of  the  right  ventricle :  its  direction  is  upwards,  back- 
Avards,  and  to  the  left  side ;  and  after  a  course  of  about 
an  inch  and  a  quarter,  it  terminates  by  dividing  into 
a  right  and  left  branch.  In  the  angle  between  these 
branches,  but  more  connected  with  the  left  than  with 
the  right,  the  ductus  arteriosus  arises:  this  vessel  in 
the  foetus  equals  in  size,  and  seems  like  a  continuation 
of,  the  pulmonary  artery;  it  terminates  in  the  concave 
side  of  the  arch  of  the  aorta,  a  little  beyond  the  origin 
of  the  left  subclavian  artery.  Superiorly,  and  to  the 
right  side  of  the  bifurcation  of  the  pulmonary  artery, 
we  see  the  bifurcation  of  the  trachea  into  the  right  and 
left  bronchial  tubes.  Between  the  division  of  the  artery 
below,  and  that  of  the  trachea  above,  we  find  a  space 
somewhat  of  a  lozenge  shape,  which  is  filled  with  a  con- 
siderable quantity  of  areolar  tissue,  a  number  of  black 
bronchial  glands,  together  with  numerous  branches  of 
the  pulmonary  plexuses  of  nerves,  chiefly  those  derived 
from  the  posterior.  The  pulmonary  artery,  after  its 
origin,  forms  a  curvature,  the  convexity  of  which  looks 
forwards  and  to  the  left  side,  and  is  covered  by  the 
serous  layer  of  the  pericardium,  with  the  interposition 
of  some  adipose  tissue:  its  concavity  looks  backwards 
and  to  the  right  side,  and  corresponds  to  the  commence- 
ment of  the  aorta:  on  either  side  it  is  related  to  the 
appendix  of  the  corresponding  auricle.     The  pulmonary 


PULMONARY   ARTERY.  55 

artery,  unlike  the  aorta,  doc8  not  in  the  undisturbed 
state  retain  its  cyhndrical  form;  this  is  owing  to  the 
comparative  thinness  of  its  proper  or  middle  elastic 
coat.  We  have  already  mentioned  that  this  vessel  and 
the  commencement  of  the  aorta  have  a  common  sheath 
formed  by  the  reflexion  of  the  serous  layer  of  the  peri- 
cardium :  within  this  sheath,  and  behind  and  between 
the  vessels,  filaments  of  the  sympathetic  nerve  descend 
to  foiTTi  the  coronary  plexuses.  If  we  now  cut  into  the 
artery,  and  examine  its  interior,  w^e  observe  that  there 
are  three  semilunar  valves  at  its  orifice,  and  that  an 
incision  through  its  anterior  part  will  divide  one  of 
them;  whereas  an  incision  into  the  anterior  part  of  the 
aorta  w^ould  nearly  separate  tw^o  of  them,  viz.,  the 
right  from  the  left. 

The  middle  or  proper  coat  of  the  pulmonar}^  artery 
will  be  found  to  take  its  origin  from  the  arterial  zona 
tendinosa  situated  at  the  termination  of  the  infundibulum 
of  the  right  ventricle,  by  a  festooned  margin  presenting 
three  convexities  or  inverted  arches,  separated  from 
each  other  by  a  small  triangular  interval,  in  which  we 
find  no  proper  arterial  tunic.  The  connection  between 
the  three  inverted  arches  and  the  zona  tendinosa  will 
be  best  seen  by  dissecting  the  parts  from  the  interior  of 
the  ventricle.  The  muscular  fibres  of  this  j)ortion  of 
the  ventricle  will  be  seen  attached  to  the  lower  margin 
of  the  tendinous  zone,  whilst  the  three  inverted  arches 
of  the  middle  coat  of  the  artery  will  be  found  con- 
nected with  its  upper  margin  by  condensed  areolar 
tissue.  Corresponding  to  each  of  the  three  small  trian- 
gular intervals  between  the  inverted  arches  of  the  middle 
coat,  Ave  will  find  a  fibrous  prolongation  sent  up  from 
the  upper  margin  of  the  zona  tendinosa ;  this  becomes 
ultimately  incorporated  with  the  condensed  areolar 
tunic  external  to  the  middle  coat.      The  endocardium 


56  OBSERVATIONS    OF   DR.    HOPE. 

within,  and  the  serous  layer  of  the  pericardium  without, 
though  but  partially,  complete  the  connection  between 
the  artery  and  the  ventricle.  Between  each  of  these 
convexities  and  the  area  of  the  vessel,  we  find  a  corre- 
sponding semilunar  valve  formed  by  the  lining  membrane 
of  the  artery,  the  concavity  of  which  looks  upwards  and 
is  strengthened  by  a  small  body  called  the  corpus  sesa- 
moideum  or  corpus  Arantii. 

The  right  pulmonary  artery  crosses  transversely  behind 
the  aorta  and  superior  cava,  to  which  consequently  its 
anterior  surface  corresponds  with  the  interposition  of 
the  serous  sheath  of  the  aorta.  Posteriorly  and  supe- 
riorly it  corresponds  to  the  right  bronchus,  and  infe- 
riorly  to  the  right  auricle. 

The  left  pulmonary  artery,  shorter  than  the  right,  and 
less  horizontal,  ascends  in  front  of  the  left  bronchus, 
being  covered  anteriorly  by  the  serous  layer  of  the  peri- 
cardium, except  in  the  immediate  vicinity  of  the  lung, 
where  it  is  covered  by  its  corresponding  veins.  Above 
and  behind  it,  is  the  arch  of  the  aorta ;  beneath  it,  in 
the  superior  wall  of  the  left  auricle,  and  in  front  of  it 
is  the  left  auricular  appendix. 

It  may  not  be  considered  out  of  place  to  quote  the 
following  observations  of  Dr.  Hoj^e,  as  to  the  relative 
positions  of  the  heart  and  its  great  vessels  with  regard 
to  the  parietes  of  the  chest. — '^  A  line  drawn  from  the 
inferior  margin  of  the  third  ribs,  across  the  sternum, 
passes  over  the  pulmonic  valves  a  little  to  the  left  of  the 
mesial  line,  and  those  of  the  aorta  are  behind  them,  but 
about  half  an  inch  lower  down.  From  this  point  the 
aorta  and  pulmonary  artery  ascend;  the  former  inclining 
slightly  to  the  right,  coming  in  contact  yith  the  ster- 
num, when   it  emerges   from  beneath  the   pulmonary 


OBSERVATIONS   OF   DR.    HOPE.  57 

artery,  and  following,  or  perhaps  rather  exceeding,  the 
mesial  line  till  it  forms  its  arch ;  the  pulmonary  artery, 
which  is,  from  the  first,  in  contact  with  the  sternum, 
inclining  more  considerably  to  the  left,  until  it  arrives 
at  the  interspace  between  the  second  and  third  ribs 
above  described.  A  vertical  line  coinciding  with  the 
left  margin  of  the  sternum  has  about  one-third  of  the 
heart,  consisting  of  the  upper  portion  of  the  right  ven- 
tricle, on  its  right;  and  two-thirds,  composed  of  the 
lower  portion  of  the  right  ventricle,  and  the  w^hole  of 
the  left,  on  its  left.  The  apex  beats  between  the  carti- 
lages of  the  fifth  and  sixth  left  ribs,  at  a  point  about  two 
inches  below  the  nipple,  and  one  inch  on  its  sternal  side. 

"  The  lungs  descend  along  the  margins  of  the  sternum, 
about  two  inches  apart,  and  overlap  the  base  of  the 
heart,  slightly  on  the  right  side  and  more  extensively  on 
the  left:  then,  receding  from  each  other,  they  leave  a 
considerable  portion  of  the  right  ventricle,  and  a  less 
extent  of  the  lower  portion  of  the  left,  in  immediate 
contact  with  the  thoracic  walls. 

"The  right  auricle  is  in  front  of  the  heart,  at  its  right 
side  and  upper  part.  One  portion  of  it  is  overlapped  by 
the  right  lung,  and  another,  principally  the  appendix,  is 
in  contact  with  the  sternum.  The  left  auricle  is  situated 
deeply  behind  and  to  the  left  of  the  heart  at  its  upper 
part,  opposite  to  the  interval  between  the  cartilages  of 
the  third  and  fourth  ribs.  The  extremity  of  the  appen- 
dix is  visible  in  front,  but,  when  the  volume  of  the 
heart  is  natural,  it  is  not  in  contact  with  the  sternum, 
being  considerably  overlapped  by  the  left  lung.  The 
auricular  orifices  are  situated  opposite  to  the  interspace 
between  the  third  and  fourth  ribs,  and  the  right  is  rather 
lower  down  than  the  left."* 

*  Hope  on  Diseases  of  the  Heart,  &c.,  pp.  3-4. 


58  THE  AORTA. 


THE  AORTA. 


The  Aorta,  or  great  systemic  artery  of  the  body,  con- 
sists of  an  arch,  and  descending  portion;  the  latter  is 
divided  into  the  thoracic  aorta,  and  the  abdominal  aorta. 
The  arch  may  be  exj)osed  by  the  dissection  already  re- 
commended for  exhibiting  the  heart :  it  extends  from  the 
base  of  the  left  ventricle  to  the  left  side  of  the  third 
dorsal  vertebra.  In  this  course  its  convexity  is  directed 
upwards,  and  its  summit  is  on  a  level  with  the  body  of 
the  second  dorsal  vertebra;  its  posterior  extremity 
touches  the  spine,  and  in  the  adult  subject  its  most 
prominent  part  is  scarcely  half  an  inch  distant  from  the 
sternum.  It  is  usually  divided  into  three  stages  or  por- 
tions, viz.,  an  anterior,  middle,  and  posterior. 

The  anterior  or  ascending  portion  arises  from  the  base 
of  the  left  ventricle,  anterior  and  a  little  to  the  right 
side  of  the  left  auriculo-ventricular  opening,  in  front  of 
the  left  side  of  the  body  of  the  fourth  dorsal  vertebra, 
and  corresponding  to  the  junction  of  the  cartilage  of  the 
fourth  rib  with  the  sternum  at  the  left  side.  From  its 
origin  it  proceeds  upwards,  forwards,  and  to  the  right 
side,  till  it  reaches  the  level  of  the  cartilage  of  the  second 
rib,  at  its  junction  with  the  cartilage  connecting  the  first 
and  second  pieces  of  the  sternum.  In  this  course  its  an- 
terior surface  is  related  to  the  pericardium,  which  sepa- 
rates it  from  the  anterior  mediastinum  and  back  of  the 
sternum;  to  the  right  coronary  artery,  the  infundibulum 
of  the  right  ventricle,  the  pulmonary  artery  at  its  origin, 
and  to  the  tip  of  the  right  auricular  appendix :  the  pos- 
terior surface  corresponds  to  a  part  of  the  left  auricle  and 
to  the  right  pulmonary  artery;  the  left  surface  is  related 
to  the  pulmonary  artery  immediately  before  it  divides; 
and  the  right  surface  first  rests  on  a  part  of  the  base  of 
the  rii?ht  ventricle  between  its  arterial   and  auricular 


ARCH    OF   THE   AORTA.  59 

openings,  and  corresponds  in  the  rest  of  its  course  to  the 
descending  or  superior  vena  cava.  The  greatest  part  of 
this  ascending  portion  is  within  the  pericardium,  the 
serous  layer  of  which  forms  a  sheath  common  to  the 
aorta  and  pulmonary  artery.  This  sheath  also  contains 
the  right  inferior  cardiac  nerve,  which  lies  between  these 
great  vessels,  in  its  course  to  the  coronary  plexus  of  the 
heart ;  together  with  the  anterior  and  posterior  cardiac 
plexuses.  We  may  observe,  also,  that  the  serous  sheath 
extends  higher  up  on  the  aorta  than  on  the  pulmonary 
artery,  and  higher  up  on  its  right  than  on  its  left  side. 
The  fibrous  layer  of  the  pericardium  is  lost  a  little  higher 
up  on  the  external  coat  of  the  artery,  by  becoming  con- 
tinuous on  this  vessel  with  the  descending  layer  of  the 
thoracic  fascia. 

If  we  look  at  the  origin  of  the  aorta  through  the  left 
ventricle,  we  observe  a  triangular  opening,  the  area  of 
which  is  more  contracted  than  any  other  part  of  the  arch 
is  naturally  found ;  immediately  outside  this  triangular 
opening  we  observe  three  small  bulgings  or  dilatations, 
called  the  sinuses  of  Valsalva ;  and  above  it  the  aorta 
enlarges  and  assumes  a  form  nearly  cylindrical,  but  not 
exactly  so,  on  account  of  certain  deviations  to  be  noticed 
hereafter.  In  order  to  examine  its  connection  with  the 
heart,  we  may  slit  up  the  front  of  it  longitudinally  from 
the  left  ventricle.  We  then  find  that  the  aorta  is  united 
to  the  heart  in  the  following  manner:  first— internally 
by  the  continuity  of  their  lining  membrane ;  secondly 
— by  the  serous  layer  of  the  pericardium,  forming  a 
sheath  passing  up  on  the  vessels  as  already  described; 
thirdly — on  removing  these  two  layers  of  membrane,  we 
find  that  the  proj)er  fibrous  tunic  of  the  artery  does  not 
present  a  straight  edge  to  the  ventricle,  but  that  it  is 
formed  into  three  distinct  arches,  the  convexities  of 
which  are  directed   towards   the    heart.     Each  of  the 


60  ARCH   OF   THE   AORTA. 

convexities,  or  festoons,  as  they  are  also  called,  is  sepa- 
rated from  its  fellow  by  a  small  triangular  interval,  the 
base  of  which  corresponds  to  the  ventricle.  The  origin 
of  the  vessel  will  thus  present  three  inverted  arches, 
separated  from  each  other  by  three  small  triangular 
spaces.  On  examining  the  base  of  the  left  ventricle  in 
this  situation,  we  observe  the  zona  fendinosa,  which  forms 
the  principal  medium  of  connection  between  it  and  the 
aorta.  The  inferior  margin  of  this  zone  is  imbedded  in 
the  muscular  fibres  of  the  ventricle,  whilst  to  its  superior 
margin  are  intimately  and  strongly  attached  by  condensed 
areolar  tissue,  the  three  convexities  already  described. 
Fourthly,  when  we  examine  the  small  triangular  inter- 
vals between  the  festoons,  after  having  removed  both  the 
serous  layer  of  the  pericardium  and  the  hning  membrane 
of  the  aorta  and  left  ventricle,  we  perceive  that  a  pro- 
cess of  fibrous  membrane,  prolonged  from  the  superior 
margin  of  the  zona  tendinosa,  fills  up  each  of  these  in- 
tervals, and  becomes  continuous  with  the  "sclerous"  or 
external  tunic  of  the  vessel. 

The  description,  therefore,  which  represents  the  lining 
membrane  of  the  artery,  and  the  serous  layer  of  the 
pericardium,  as  being  "  in  apposition"  in  these  triangular 
spaces,  is  not  correct.  The  processes  from  the  tendinous 
zone  which  fill  up  the  intervals  between  the  three  con- 
vexities may  be  easily  demonstrated :  they  are  by  no 
means  so  strong  as  the  rest  of  the  ring,  but,  though  very 
delicate,  have  considerable  resistance,  and  are  separated 
from  the  serous  layer  of  the  pericardium  by  areolar  tissue 
continuous  with  the  external  tunic  of  the  artery.  It  is 
clear,  however,  that  the  lining  membrane  of  the  aorta 
and  serous  layer  of  the  pericardium  could  not  possibly 
be  in  apposition  in  that  situation,  w^here  the  pulmonary 
artery  and  aorta  are  in  contact  with  each  other,  and 


ARCH    OF   THE   AORTA.  61 

where  the  serous  layer  of  the  pericardium  does  not  dip 
in  between  these  vessels. 

On  the  inside  of  the  aortic  opening  w^e  find  three  folds 
of  the  lining  membrane  forming  three  semilunar  valves^ 
the  inferior  convex  margins  of  which  are  attached  oppo- 
site to  the  convex  margins  of  the  three  inverted  arches; 
their  free  or  concave  margins  look  upwards,  and  each  of 
them  is  strengthened  in  its  centre  by  a  small  prominent 
body  termed  the  corpus  Arantii,  or  corpus  sesamoideum. 
When  the  aorta  contracts,  these  valves  are  thrown  away 
from  the  walls  of  the  artery,  inwards  towards  the  centre 
or  area  of  the  aortic  oj^ening,  and  thus  prevent  the 
return  of  blood  into  the  ventricle :  this  object  is  sup- 
posed to  be  more  completely  effected  by  the  corpora 
Arantii  closing  up  at  that  instant  the  small  triangular 
space  which  would  otherwise  exist  at  the  common  centre 
of  approximation  of  the  three  semilunar  valves.  Corre- 
sponding to  the  outer  surfaces  of  these  valves,  the  aorta 
presents  three  pouches  or  dilatations  termed  the  lesser 
sinuses  of  the  aorta,  or  sinuses  of  Valsalva.  These  exist 
at  birth,  but  are  better  marked  in  the  adult  than  in  the 
young  subject,  on  account  of  the  constant  pressure  of 
the  blood  during  the  contraction  of  the  vessel.  By  the 
great  sinus  of  the  aorta  is  meant  an  enlargement  of  the 
tube  at  the  upper  part  of  its  first  stage,  where  the  vessel 
begins  to  change  its  direction.  It  does  not  engage  the 
whole  circumference  of  the  tube,  but  is  limited  to  its 
anterior  and  right  side.  It  is  obviously  the  effect  of  the 
impulse  of  the  blood  from  the  left  ventricle,  and  is  there- 
fore better  marked  in  the  old  than  in  the  young  subject. 

If  a  cast  of  the  interior  of  the  aorta  be  taken  in  wax 
or  plaster,  it  will  present  at  its  origin  three  distinct 
bulgings,  corresponding  to  the  sinuses  of  Valsalva;  these 
bulgings  will  appear  to  be  separated  from  each  other  by 
three  small  fissures,  which  unite  in  the  centre  of  the  area 


62  ARCH    OF    THE    AORTA. 

of  the  artery :  the  same  observation  applies  to  the  pul- 
monary artery. 

The  middle  portion  of  the  arch  passes  obliquely  up- 
wards, backwards,  and  to  the  left  side,  so  that  the  term 
transverse,  usually  applied  to  it,  is  not  correct:  it  ter- 
minates on  the  left  side  of  the  body  of  the  second  dorsal 
vertebra:  posteriorly  it  is  related  to  the  lower  extremity 
of  the  trachea,  to  the  great  cardiac  plexus  of  nerves,  to 
the  thoracic  duct,  and  left  recurrent  nerve :  anteriorly,  to 
the  thymus  gland  in  the  early  periods  of  life ;  to  the  left 
pneumogastric  nerve,  and  also  to  the  recurrent  nerve, 
and  to  some  small  branches  of  the  sympathetic  nerve, 
derived  from  the  superior  cardiac  nerve,  which  here  unite 
with  the  recurrent :  above  it  are  the  left  vena  innominata, 
to  which  it  is  united  by  a  dense  aponeurosis,  connected 
below  with  an  expansion  of  the  fibrous  layer  of  the  peri- 
cardium, and  above  with  a  deep-seated  jDrocess  of  the 
cervical  aponeurosis,  which  covers  the  origins  of  the 
carotid  and  subclavian  arteries,  and  the  arteria  innomi- 
nata :  the  origins  of  the  great  arterial  trunks  given  off 
regularly  from  this  stage  of  the  aorta,  viz.,  the  arteria 
innominata,  the  left  carotid,  and  left  subclavian,  are 
necessarily  situated  above  it.  Beneath  it,  or  corresponding 
to  its  concave  portion,  are,  the  left  recurrent  nerve,  the 
right  pulmonary  artery,  portion  of  the  left  auricle,  the 
root  of  the  left  lung,  sometimes  the  cardiac  ganglion  of 
Wrisberg,  and  the  ligamentous  chord  which  in  intra- 
uterine life  had  been  the  ductus  arteriosus :  this  structure 
enters  the  concavity  of  the  arch  at  a  point  corresponding 
inferiorly  to  the  origin  of  the  left  subclavian  artery  from 
the  convexity  of  the  vessel,  but  a  little  nearer  to  its  left 
side.  The  left  recurrent  nerve  curves  underneath  that 
portion  of  the  aorta  which  is  joined  by  the  ductus  arte- 
riosus, so  that  the  nerve  embraces  within  its  curve  the 
termination  of  the  ligamentous  remains  of  this  latter 


ARCH    OF    THE   AORTA. 


63 


Fig.  6. — Dissection  to  show  the  relations  of  the  Vessels  and  Nerves  in  the  lower  part  of 
Neck ;  and  some  of  the  relations  of  the  Arch  of  the  Aorta  and  its  Branches.  Pericar- 
dium opened,  and  portions  of  Heart  exposed. 


A,  Right  Ventricle  of  the  Heart,  B,  Pulmonary  Artery  and  Infundibulum.  C,  Ascending  Aorta, 
D,  Right  Auricular  Appendix.  E,  Pericardium.  F,  Superior  Vena  Cava.  G,  Left  Pneumogastric 
Nerve,  with  loop  of  left  Recurrent  Nerve:  Phrenic  Nerve  to  their  left  side.  H,  Middle  portion  of  the 
Arch  of  Aorta.  I,  Left  Vena  Innominata.  K,  Right  Vena  Innominata.  L,  Lower  end  of  left  In- 
ternal Jugular  Vein  cut.  M.  Right  Subclavian  Vein,  N,  Right  Internal  Jugular  Vein  about  to  join 
Subclavian  Vein.  O,  Arteria  lunominata.  P,  Right  Subclavian  Artery  crossed  by  Right  Pneumo- 
gastric Nerve,  and  in  loop  of  Right  Recnrrent  Nerve.  Q,  Right  common  Carotid  Artery.  R,  Lefl 
common  Carotid  Artery.  S,  Left  Subclavian  Artery  in  relation  with  left  Pneumogastric  Nerve.  T, 
Third  stage  of  left  Subclavian  Artery,  V,  Left  Scalenus  Anticus  Muscle,  with  Phrenic  Nerve.  W,  W, 
First  Ribs.  X,  X,  Fifth  Ribs  cut  across.  Y,  Y.  Right  and  Left  Maniills.  Z,  Lower  part  of  Ster- 
num, a,  Thyroid  body,  b.  Trachea,  c,  Lefl  Internal  Jugular  Vein  cut  across,  d,  Left  Subclavian 
Vein,  e.  Clavicle  cut  across,  and  drawn  downwards,  f,  Brachial  Plexus  of  Nerves,  g.  Inferior 
Thyroid  Artery,  passing  behind  the  cut  extremity  of  Internal  Jugular  Vein,  Pneumogastric  Nerve, 
and  Carotid  Artery. 


64  ARCH   OF   THE   AORTA. 

vessel  as  well  as  the  concavity  of  the  arch  of  the 
aorta. 

The  jposterior  or  descending  portion  of  the  arch  extends 
from  the  body  of  the  second  to  that  of  the  third  dorsal 
vertebra :  posteriorly,  and  at  its  right,  it  rests  against  the 
spine  and  left  longus  colli  muscle ;  on  its  right  side  also 
are  the  oesophagus,  thoracic  duct,  and  vena  azygos  :  an- 
teriorly it  is  covered  by  the  root  of  the  left  lung;  and 
on  its  left  side  the  left  lung  and  pleura  are  situated. 
In  these  different  stages,  besides  the  various  relations 
already  enumerated,  the  artery  is  surrounded  by  a  num- 
ber of  dark-colored  bronchial  glands  :  when  these  be- 
come enlarged  by  disease,  to  which  they  are  very  liable, 
they  occasionally  produce  most  serious  eifects  by  their 
pressure  on  the  air-tubes,  on  the  vena  cava,  and  on  the 
large  arteries  of  the  neck  which  they  accompany. 

Taking  the  entire  of  the  arch  of  the  aorta,  we  will  find 
the  following  parts  embraced  within  its  concavity:  first, 
the  right  pulmonary  artery;  second,  that  portion  of  the 
left  auricle  with  which  the  appendix  is  connected;  third, 
the  left  division  of  the  trachea;  fourth,  the  cardiac 
ganglion  of  Wrisberg;  fifth,  the  ligamentous  remains  of 
the  ductus  arteriosus ;  sixth,  the  left  recurrent  nerve. 

The  arch  of  the  aorta  has  important  venous  relations  : 
we  may  observe  the  superior  vena  cava,  when  all  the 
vessels  are  moderately  filled,  lying  to  the  right  side  of 
the  first  stage  of  the  arch,  and  the  left  vena  innominata, 
lying  above,  and  very  near  the  upper  margin  of  the 
second  stage.  The  student  would  do  well  to  attend  to 
the  anatomy  of  these  venous  trunks :  he  will  perceive, 
after  opening  the  pericardium,  a  large  vein  presenting  a 
dark  blue  color,  lying  to  the  right  of  the  aorta :  this  is 
the  vena  cava  superior  or  descendens;  it  is  covered, 
except  at  its  most  posterior  part,  by  the  serous  layer  of 
the  pericardium:  it  is  about  three  inches  in  length;  it 


ARCH    OF    THE   AORTA.  65 

enters  the  fibrous  layer  of  the  pericardium,  so  that  about 
one-third  of  the  vessel  is  contained  within  this  sac;  and 
it  is  situated  entirely  within  the  thorax.  It  is  formed 
chiefly  by  the  confluence  of  the  right  and  left  venae  inno- 
minatae,  or  brachio-cephalic  veins  :  this  union  takes  place 
about  an  inch  and  a  half  below  the  bifurcation  of  the 
arteria  innominataj  and  corresponds  anteriorly  to  the 
upper  part  of  the  second  rib,  near  its  articulation  with 
the  right  side  of  the  sternum.  The  vein  descends  nearly 
in  a  vertical  direction,  but  slightly  curved,  the  concavity 
being  directed  to  the  left,  and  corresponding  to  the  right 
side  of  the  first  stage  of  the  aorta ;  the  convexity  is  to 
the  right  side.  It  here  lies  anterior  to  the  right  pulmo- 
nary vessels,  and  enters  into  the  upper  part  of  the  right 
auricle  behind  the  auricular  appendix.  The  vena  azygos 
enters  the  cava  at  its  posterior  surface,  just  before  this 
large  vein  passes  into  the  pericardium.  The  other  veins 
which  pour  their  blood  into  the  superior  cava,  are,  the 
right  inferior  thyroid  and  internal  mammary  veins,  the 
thymic,  pericardial,  mediastinal,  and  right  suj^erior 
phrenic  :  these  veins  usually  enter  the  vessel  at  its  com- 
mencement, and  in  its  extra-pericardial  stage.  In  this 
stage  the  vein  has  numerous  relations :  behind  it  we  ob- 
serve the  vena  azygos,  a  portion  of  the  trachea,  the  right 
vagus  nerve,  some  lymphatic  glands,  and  loose  areolar 
tissue ;  to  the  outside^  we  have  the  right  phrenic  nerve, 
the  right  pleura  and  lung;  anteriorly^tha  remains  of  the 
thymus  gland,  some  areolar  tissue  belonging  to  the  an- 
terior mediastinum,  and  the  phrenic  nerve;  and  to  its 
left  or  inner  side  we  have  the  arch  of  the  aorta. 

The  arch  of  the  aorta  being  in  close  relation  both  to 
the  anterior  and  posterior  walls  of  the  chest,  as  well  as 
to  its  interior,  and  being  surrounded  by  numerous  cavi- 
ties and  tubes,  it  is  evident  that  an  aneurismal  tumor 
affecting  this  portion  of  the  vessel  may  open  in  a  great 

6* 


66  ARCH    OP   THE   AORTA. 

variety  of  situations.  We  frequentl}^  find  it  absorbing 
the  sternum  at  its  junction  with  the  cartilage  of  the 
second  or  third  rib  of  the  right  side,  and  pointing,  or 
even  opening,  anteriorly.  It  has  also  been  known  to 
burst  into  the  right  auricle  of  the  heart,  into  the  peri- 
cardium, the  pulmonary  artery,  the  trachea,  bronchial 
tubes,  and  air-cells;  into  the  mediastinum,  oesophagus, 
right  and  left  pleuras,  and  into  the  spinal  canal;  also  to 
press  upon  and  obstruct  the  thoracic  duct,  or  obliterate 
the  subclavian  or  common  carotid  artery.  In  some  eases 
the  tumor  ascends  behind  and  above  the  clavicle,  and 
simulates  subclavian  or  carotid  aneurism ;  in  other  cases 
its  pressure  anteriorly  has  been  known  to  dislocate  the 
clavicle,  and  the  occurrence  of  dyspnoea,  aphonia,  and 
dysphagia  during  its  progress  can  be  accounted  for  by 
pressure  on  the  air-passages,  recurrent  nerve,  and  oeso- 
phagus. 

Mr.  Smith  has  described  a  very  remarkable  case  of 
aneurism  of  the  ascending  portion  of  the  aorta,  the 
front  of  which  was  divided  by  the  pulmonary  artery 
into  two  portions,  one  of  which  projected  into  the  right 
ventricle,  and  the  other  into  the  left.  From  each  of 
these  cavities  the  sac  was  divided  only  by  a  very  deli- 
cate membrane,  that  must  have  been  absorbed  had  the 
patient  lived  a  very  little  longer.* 

Development  of  the  Aorta. — This  vessel  is  formed  after 
the  portal  s^^stem,  with  which  it  is  connected  by  a  dila- 
tation which  is  the  rudiment  of  the  future  heart.  In 
the  young  child  it  lies  nearer  the  sjDine  than  in  the 
adult,  on  account  of  the  larger  size  of  the  thymus  gland 
which  lies  in  front  of  it,  and  the  comparatively  imper- 
fect development,  at  this  period  of  life,  of  the  trachea 
and  bronchial  tubes,  which  are  situated  behind  it :  but  as 

*  Dublin  Journal,  vol.  ix. 


ARTERIA   INNOMINATA.  67 

the  right  bronchus  becomes  developed,  and  the  thymus 
gland  absorbed,  the  arch  of  the  aorta  advances  nearer 
to  the  sternum.  We  also  find  that  in  the  young  subject 
the  arch  is  situated  higher  up  than  in  the  adult:  this  is 
owing  to  the  thorax  of  the  child  having  less  proportional 
height ;  and  for  the  same  reason  the  arch  is  higher  in 
the  adult  female  than  in  the  male.  In  some  cases  we 
find  it  unnaturally  high,  independently  of  the  age  or 
sex  of  the  individual.  In  the  old  subject  the  swell  of 
the  arch  is  considerably  increased  by  the  development 
of  the  great  sinus.  If  a  vertical  section  be  made  of  the 
arch  of  the  aorta,  the  convexity  of  the  arch  will  be 
found  to  be  thicker  than  the  concavity. 

BRANCHES   OF   THE   ARCH   OF   THE   AORTA.' 

From  the  Arch  of  the  Aorta  five  branches  usually 
arise,  viz. : 

-r,  -r  ^  f  From  the  ascendins: 

Eight  and  Left  Coronary,  .     .\        ^.        ^^,  , 

'  [portion  of  the  arch. 

Arteria  Innominata,  Left  Caro-  TFrom  the  middle  por- 
TiD,  and  Left  Subclavian,  .jtion  of  the  arch. 

The  anatomy  of  the  two  coronary  arteries  has  been 
already  described. 

arteria  innominata. 

The  Arteria  Innominata,  or  Brachio-cephalic  artery, 
arises  from  the  arch  of  the  aorta  at  the  commencement 
of  its  second  stage,  and  corresponding  to  the  termina- 
tion of  the  great  sinus  of  Morgagni;  it  lies  on  the  front 
of  the  trachea,  a  little  to  the  left  side  of  the  middle  line, 
and  on  a  level  with  the  cartilage  of  the  second  rib. 
From  its  origin  it  proceeds  upwards,  backwards,  and  to 
the  right  side,  to  terminate  behind  the  right  sterno- 
clavicular articulation  by  dividing  into  the  right  sub- 
clavian and  right  carotid  arteries.   If  a  needle  be  passed 


68  ARTERIA   INNOMINATA. 

directly  backwards  and  immediate^  on  a  level  with  the 
top  of  the  sterno-elavicular  articulation  of  the  right 
side,  it  will  be  found  to  pass  between  the  two  origins  of 
the  sterno-mastoid  muscle  and  through  the  angle  formed 
by  the  bifurcation  of  the  arteria  innominata  into  the 
right  subclavian  and  carotid  arteries.  The  arteria  inno- 
minata varies  in  length  from  an  inch  to  about  an  inch 
and  a  half:  it  may  be  dissected  either  from  the  neck  or 
from  the  interior  of  the  thorax;  and  the  student  is 
recommended  to  adopt  both  of  these  methods.  On  dis- 
secting from  the  neck  downwards  to  the  thorax,  the 
following  parts  will  be  found  related  to  the  artery. 
Anteriorly,  after  removing  the  integuments  and  fascia 
of  the  neck,  we  see  the  sternal  origin  of  the  sterno- 
cleido-mastoid  muscle,  the  first  bone  of  the  sternum,  the 
sterno-clavicular  articulation,  and  the  sterno-hyoid  and 
sterno-thyroid  muscles:  near  the  origin  of  the  artery 
the  loft  vena  innominata,  with  Avhich  it  is  connected  by 
the  descending  layer  of  the  thoracic  fascia,  crosses  in 
front  of  it;  and  still  higher  up,  in  the  young  subject,  the 
thymus  gland.  Posteriorly,  the  artery  rests  upon  the 
trachea:  on  its  left  side  we  find  the  middle  and  inferior 
thyroid  veins,  and  occasionally  a  middle  thj^roid  artery, 
which  separates  it  from  the  left  carotid.  On  its  right 
side,  and  on  a  plane  anterior  to  it,  we  observe  the  right 
vena  innominata,  and  between  the  two  vessels  the  pneu- 
mogastric  nerve  runs  in  close  relation  to  the  bifurca- 
tion of  the  artery:  still  more  externally  than  the  vagus, 
the  i^hrenic  nerve  may  be  seen  lying  behind  the  right 
vena  innominata ;  and  in  its  passage  to  the  outside  of 
the  suj^erior  vena  cava,  still  lower  down,  the  vessel  is 
accompanied  by  the  inferior  cardiac  nerve  or  nerves : 
the  superior  part  of  the  parietal  division  of  the  right 
pleura  is  situated  inferior  and  external  to  the  artery. 
AVe  have  spoken  of  a  fascia  in  connection  with  the  left 


ARTERIA   INNOMINATA.  69 

vena  innominata,  as  it  passes  across  the  arteria  innomi- 
tiata:  this  fascia  will  be  found  to  connect  not  merely 
these  two  vessels  with  one  another,  and  to  afford  them 
coverings,  but  by  a  deeper-seated  process  to  connect  the 
artery  with  the  trachea,  to  which  latter  tube  also  it 
furnishes  an  investment.  This  fascia  has  been  described 
by  Sir  A.  Cooper  as  enveloping  these  vessels,  connecting 
them  with  the  bones  which  form  the  opening  of  the 
thorax,  and  continuous  with  the  fibrous  portion  of  the 
pericardium.  He  also  describes  this  fascia  as  conti- 
nuous above  with  the  dee2>seated  fascia  of  the  neck  de- 
scribed by  Burns.* 

Mr.  Godman,  of  Philadelphia,  also  described  this  the 
thoracic  fascia,  and  its  continuity  with  the  pericardium 
and  fascia  of  the  neck.f 

The  anatomy  of  the  great  venous  trunks  in  relation  to 
the  arteria  innominata,  next  demands  our  attention. 
The  left  vena  innominata  will  be  seen  crossing  obliquely 
above  the  middle  portion  of  the  arch  of  the  aorta,  in 
front  of  the  left  carotid,  trachea,  and  arteria  innomi- 
nata, downwards  and  towards  the  right  side  of  this 
latter  vessel,  a  distance  of  about  three  inches.  The 
right  vena  innominata  will  be  seen  passing  in  a  more 
vertical  direction,  but  taking  a  shorter  course,  and 
ranging  below  the  level  of  the  first  stage  of  the  right 
subclavian  artery.  The  two  venae  innominatse  unite  to 
form  the  vena  cava  descendens,  upon  a  plane  anterior 
and  to  the  right  of  the  arteria  innominata,  and  about 
half  an  inch  below  its  bifurcation.  An  intervascular 
space  will  be  found  in  this  situation,  formed  superiorly 
and  internally  by  the  trunk  of  the  arteria  innominata 


*  Anatomy  of  the  Thymus  Gland,  p.  24. 

f  Anatomical   Investigations,  by    John   D.   Godman,  in   Philadelphia 
Journal,  1824. 


70  ARTERIA   INNOMINATA. 

and  part  of  the  right  subclavian  artery;  inferiorly  and 
to  the  right  side  by  the  ri^ht  vena  innominata;  inter- 
nally the  interval  is  closed  by  the  termination  of  the 
left  vena  innominata  in  the  vena  cava  descendens;  and 
stiperiorly  by  the  internal  jugular  uniting  with  the  sub- 
clavian vein  to  form  the  right  vena  innominata.  This 
interval  will  be  found  to  contain  a  quantity  of  loose 
areolar  tissue,  the  vagus  nerve,  and  the  origin  of  its 
recurrent  branch  or  inferior  laryngeal  nerve,  which 
may  be  seen  in  this  situation'  passing  underneath  the 
right  subclavian  artery:  the  inferior  cardiac  nerve  will 
be  found  here  also  :  the  layer  of  fascia,  already  described 
as  continuous  with  the  deep  layer  of  the  cervical  fascia, 
covers  all  these  parts.  It  is  this  space  which  the  sur- 
geon's aneurism-needle  must  traverse  in  the  operation 
of  tying  the  arteria  innominata. 

If  the  dissection  of  the  artery  be  made  from  the  chest, 
the  apex  of  the  right  lung  should  be  drawn  downward; 
the  finger  may  be  then  passed  upwards  into  the  summit 
of  the  supra-clavicular  region,  so  as  to  pass  behind  the 
middle  stage  of  the  right  subclavian  artery;  it  will  be 
then  found  that  the  parietal  layer  of  the  pleura  will 
ascend  from  the  thorax  into  this  region,  forming  the 
apex  of  the  cone  of  the  pleura.  If  the  finger  be  now 
pressed  internally  and  anteriorly,  the  under  surface  of 
the  arteria  innominata  may  be  felt,  through  the  pleura. 

If  a  vertical  section  of  the  arteria  innominata  and 
arch  of  the  aorta  be  made,  the  right  wall  of  the  former 
vessel  will  be  observed  to  form  nearly  a  directly  con- 
tinuous surface  with  the  convexity  of  the  arch;  whilst 
its  left  wall  will  be  seen  forming  a  spur-like  iDrojection 
into  the  aorta:  a  considerable  amount  of  the  column 
of  blood  issuing  from  the  heart  will  be  thus  directed 
into  the  arteria  innominata.  The  same  observation  will 
apply  to  the  origins  of  the  left  carotid  and  left  subcla- 


LIGATURE   OF   THE   ARTERIA   INNOMINATA. 


71 


vian  arteries,  though  in  these  vessels  the  arrangement 
is  not  so  distinctly  seen. 

Operation  of  tying  the  arteria  innominata. — This  opera- 
tion has  been  performed  in  about  ten  cases :  in  nine  for 
subclavian  aneurisms;  and  in  one,  where  hemorrhage 
took  j)lace  after  ligature  of  the  subclavian :  all  these 
cases  were  attended  with  fatal  results. 


LIGATURE    OP    THE    ARTERIA    INNOMINATA. 


Date  of 

No. 

Operator. 

Operation. 

Results  and  Observations. 

r  Death  on    the  26th  day,  from 

1 

Mott  of  New  York.,.. 

1818 

-|      hemorrhage :    ligature    came 

(     away  on  the  14th  day. 

2 

Norman  of  Bath 

1824 

Death. 
'Death  on   the  67th  day,  from 

3 

Graefe  of  Berlin 

1829 

hemorrhage:    ligature   came 
away  on  the  14th  day. 

4 

Arendt,    a    Russian 
surgeon  

1830 

Death   on    the   8th    day,   from 
inflammation    of   the    lungs, 
pleura,  and  aneurismal  sac. 

^\A.l.  ^\J\J MJ. } 

5 

Bland    of     Sydney, 
New  South  Wales  / 

1832 

Death  on  the   18th    day,  from 
hemorrhage. 

Death   on   the   5th    day,   from 

6 

Hall  of  Baltimore 

1833 

hemorrhage.      Coats    of    the 
artery  were  diseased. 

1 

A  Parisian  surgeon ;  ~ 
— case  alluded  to 

by         Dupuytren, 
Cliniquo     Chirur- 

1834 

Death  from  hemorrhage. 

gicale,    vol.   iv.  p. 

611 

1837 

8 

Lizars  of  Edinburgh 

f  Death   on   the  21st  day,  from 
1      hemorrhage. 

9 

Hutin,     a      French  | 
surgeon J 

1842 

f  Death   in    12   hours,  from   he- 
\      morrhage. 

Death  on  the  9th  day. 

10 

Cooper  of  San  Fran- 
cisco   

1859 

In  the  year  1831,  Professor  Porter,  of  this  city,  ex- 
posed the  artery  for  the  purpose  of  including  it  in  a 
ligature,  but,  finding  it  diseased  throughout  its  entire 


72  LIGATURE    OF   THE   ARTERIA   INNOMINATA. 

length,  he  thought  it  advisable  not  to  tie  the  vessel: 
the  wound  was  therefore  closed.  After  some  time  the 
tumor  had  undergone  considerable  diminution  in  size, 
and  when  the  patient  left  the  hospital  it  had  become 
nearly  consolidated,  and  the  pulsation  had  almost 
ceased.*  A  nearly  similar  case  occurred  in  the  practice 
of  Mr.  Key.  The  operator  attempted  to  pass  the  liga- 
ture round  the  arteria  innominata,  but  did  not  persevere. 
On  the  18th  day  the  patient  was  going  on  tolerably  well, 
but  the  sac,  increasing  in  size,  pressed  upon  the  trachea, 
and  stopped  respiration.  The  patient  died  on  the  23d 
day  after  the  opera tion.f 

In  none  of  these  cases  did  the  sudden  abstraction  of 
blood  from  the  head,  neck,  and  right  upper  extremity 
produce  any  serious  consequence,  or  even  inconvenience; 
though,  as  Dr.  Mott  observes,  "to  intercept  suddenly 
one-fourth  quantity  of  blood  so  near  the  heart,  without 
producing  some  unpleasant  effect,  no  surgeon,  a  priorij 
would  have  believed  possible."  The  profession  were  not, 
however,  altogether  unprepared  for  these  important  re- 
sults; for  cases  were  occasionally  observed  in  which  the 
obstru-ction  of  considerable  trunks  supplying  the  brain, 
did  not  appear  to  be  followed  by  any  alarming  con- 
sequence. Thus  Pclletan  dissected  a  case  in  which  the 
right  subclavian,  right  carotid,  and  termination  of  the 
arteria  innominata,  had  been  completely  impervious 
during  life,  without  having  produced  any  serious  con- 
sequence; and  Mr.  W.  Barrach  has  related  a  similar 
case,  except  that  the  right  subclavian  was  in  this  in- 
stance pervious. 

Mode  of  performing  the  operation. — The  patient  should 
lie  on  his  back  on  a  table,  with  both   the  shoulders 


«■  Dub.  Jour.  1832,  vol.  i. 

t  Crisp  on  "Diseases  of  the  Blood-Vessels,"  p.  206. 


LIGATURE    OF   THE   ARTERIA   INNOMINATA.  73 

thrown  forwards,  the  right  being  at  the  same  time 
drawn  forcibly  downwards,  and  the  head  leaning  back- 
wards, and  to  the  left  side.  An  incision  should  then 
be  made  transversely  from  the  external  margin  of  the 
sterno-cleido-mastoid  muscle  parallel  to  and  above  the 
clavicle,  till  it  terminates  opposite  the  trachea :  a  second 
incision  is  then  to  be  made  along  the  anterior  margin  of 
the  sterno-cleido-mastoid  muscle,  about  three  inches  in 
length,  and  terminating  inferiorly  at  the  internal  ex- 
tremity of  the  preceding  incision.  On  raising  the  flap, 
the  sterno-cleido-mastoid  muscle  is  brought  into  view : 
under  this  a  director  should  be  conveyed  from  within 
outwards,  keeping  it  close  to  the  muscular  fibres,  in 
order  to  exclude  the  veins  and  nerves  in  this  situation. 
On  this  we  divide  the  sternal,  and  part  (almost  all,  ac- 
cording to  Guthrie)  of  the  clavicular  origin  of  the  muscle. 
We  then,  by  a  similar  proceeding,  divide  successively 
the  sterno-hyoid  and  sterno-thyroid  muscles  of  the  right 
side  above  the  sternum.  With  the  nail,  or  handle  of 
the  scalpel,  we  should  now  tear  through  the  dense  aponeu- 
rosis covering  the  carotid  artery,  and  in  the  same  way 
dissect  the  small  veins  in  this  situation,  not  using  the 
cutting  edge  of  the  knife  as  long  as  we  can  avoid  it. 
When  the  carotid  artery  is  exposed,  it  will  serve  (unless 
there  be  an  irregularity)  to  conduct  the  finger  to  the 
arteria  innominata,  which,  on  account  of  the  patient's 
position,  will  be  drawn  up  from  the  thorax.  The  left 
vena  innominata  should  now  be  depressed,  and  the 
aneurism-needle  passed  from  without  inwards  and  up- 
wards, keeping  it  close  to  the  vessel  to  avoid  the  pleura, 
and  the  pneumogast!»ic  and  inferior  cardiac  nerves,  all  of 
which  are  on  its  right  side.  By  tying  the  artery  near 
its  termination,  there  is  more  room  left  for  the  forma- 
tion of  an  internal  coagulum.  After  the  needle  is  passed 
underneath  the  vessel,  considerable  difficulty  is  often 

7 


74  LIGATURE    OF   THE   ARTERIA   INNOMINATA. 

experienced  in  depressing  its  handle,  so  as  to  raise  its 
point  sufficiently  on  the  opposite  side :  it  became  desir- 
able, accordingly,  that  some  means  should  be  contrived 
to  obviate  this  difficulty,  and  facilitate  the  conveyance 
of  the  ligature  in  deep  situations.  For  this  purpose 
a  very  ingenious  instrument  has  been  invented  by  Mr. 
L'Estrange,  of  this  city. 

Two  other  methods  have  been  proposed  to  effect  a 
ligature  of  the  arteria  innominata.  The  first  is  to  trepan 
the  upper  piece  of  the  sternum,  and  tie  this  vessel  below 
the  left  vena  innominata :  this  is  a  most  objectionable 
proceeding.  The  second  has  been  proposed  originally 
by  Dr.  O'Donnell,  of  Liverpool,*  and  subsequently  re- 
commended by  Yelpeau:  the  following  is  an  abridged 
account  of  it;  the  operator  stands  at  the  left  side  of  the 
patient's  head ;  an  incision  is  to  be  made  through  the 
skin,  commencing  at  the  internal  margin  of  the  left 
sterno-mastoid  muscle,  and  carried  downwards  and  to- 
wards the  right  side  for  the  extent  of  about  two  inches. 
The  next  incisions  should  divide  the  two  layers  of  fascia 
in  this  situation,  so  as  to  expose  the  trachea.  The 
middle  thyroid  artery,  if  present,  and  veins,  are  to  bo 
pushed  aside,  and,  if  necessary,  tied.  The  index  finger 
is  now  made  to  glide  between  the  right  sterno-hyoid 
muscle  and  the  trachea,  in  order  to  detect  the  arteria 
innominata.  The  operator  then  passes  a  curved  staff 
with  great  caution  and  management  from  before  back- 
wards, between  the  artery  and  vena  cava  superior.  The 
posterior  surface  of  the  vessel  is  next  to  be  denuded, 
and  raised  with  the  staff  in  the  same  cautious  manner. 
Guided  by  this,  the  "stylet  port  £1"  should  be  intro- 
duced from  left  to  right,  and  from  behind  forwards. 
Yelpeau  says,  that  this  operation  is  incontestably  more 

*  Cyclopaedia  of  Practical  Surgery,  vol.  i.  p.  260. 


COMMON    CAROTID   ARTERIES.  75 

simple,  more  rational,  and  less  dangerous  than  any  other; 
and  has,  moreover,  this  advantage,  that  the  same  pro- 
ceeding will  serve  for  the  ligature  of  either  of  the  sub- 
clavians  in  the  first  stage,  or  either  of  the  carotids  near 
its  origin.  Unfortunately,  however,  no  matter  how 
simple  the  steps  of  the  operation  may  be  made  for  in- 
eluding  the  arteria  innominata  in  a  ligature,  the  results 
of  the  operation  have  been  so  uniformly  fatal  that  the 
surgeon  has  nothing  to  encourage  him  in  its  adoption. 


COMMON   CAROTID  ARTERIES. 

The  common  carotid  of  the  right  side  arises  from  the 
arteria  innominata  at  the  superior  outlet  of  the  thorax, 
behind,  and  on  a  level  with  the  upper  portion  of  the 
right  stern o-clavicular  articulation,  and  between  the 
sternal  and  clavicular  origins  of  the  right  sterno-cleido- 
mastoid  muscle.  On  the  left  side  it  arises  within  the 
thorax,  from  the  arch  of  the  aorta.  As  the  two  common 
carotid  arteries  ascend  in  the  ueck  they  separate  from 
each  other,  and  terminate  one  on  either  side  opposite  the 
superior  margin  of  the  thyroid  cartilage,  below  the  great 
cornu  of  the  os  hyoides,  and  at  a  point  corresponding  to 
about  the  third  cervical  vertebra,  about  an  inch  below  the 
angle  of  the  lower  jaw.  In  this  course  they  are  separated 
inferiorly  by  the  trachea  and  oesophagus,  and  superiorly, 
at  a  greater  distance,  by  the  larynx  and  pharynx.  Each 
of  the  carotid  arteries  is  contained  within  a  fibrous 
sheath,  formed  by  a  process  of  the  deep  cervical  fascia; 
the  internal  jugular  vein  and  pneumogastric  nerve  are 
also  contained  within  it.  The  tendinous  centre  of  the 
omo-hyoid  muscle  may  be  seen  crossing  in  front  of  the 
sheath,  and  attaching  itself  intimately  to  it,  nearly 
opposite  the  cricoid  cartilage.  The  common  carotid  of 
each  side  may  be  thus  considered  as  divided  into  two 


76  COMMON   CAROTID   ARTERIES. 

stages, — one  below  the  omo-hyoid  muscle,  the  other  above 
it.  We  shall  first  describe  the  relations  of  the  right 
common  carotid  artery  in  these  two  stages,  then  the 
course  and  relations  of  the  left,  and  afterwards  point 
out  the  differences  between  them. 

First  or  inferior  stage  of  the  right  Common  Carotid. — 
This  vessel,  as  has  been  stated,  arises  from  the  arteria 
innominata  immediately  behind  the  upper  part  of  the 
sterno-clavicular  articulation,  and  inclines  a  little  back- 
wards as  it  ascends  in  the  neck.  In  this  stage  it  is 
covered  anteriorly  by  the  integuments,  by  the  platysma 
myoides  (except  in  the  immediate  neighborhood  of  its 
origin  from  the  innominata) ) — more  deeply  by  the  sterno- 
mastoid  enclosed  within  a  proper  sheath  of  the  cervical 
fascia;  by  the  sterno-hyoid  and  sterno-thyroid  muscles, 
and  still  deeper,  by  branches  of  the  descendens  noni 
nerve,  and  by  the  cervical  fascia.  When  the  sterno- 
mastoid  muscle  is  largely  developed,  its  sternal  portion 
considerably  overlaps  the  artery  after  its  origin  from  the 
arteria  innominata.  Internally  it  is  related  to  the  trachea, 
oesophagus,  and  thyroid  gland,  which  often  overlaps  it; 
and  to  the  larynx  and  inferior  portion  of  the  pharynx. 
Externally  it  is  related  to  the  internal  jugular  vein  and 
-pneumogastric  nerve,  which  latter  lies  deeply  concealed 
between  the  artery  and  vein, — the  nerve,  artery,  and  vein 
being  contained  in  a  common  sheath  of  fascia:  sometimes 
a  distinct  septum  of  the  same  structure  passes  from  the 
front  to  the  back  part  of  the  sheath,  so  as  to  separate  the 
artery  from  the  vein.  Posteriorly,  it  is  crossed  by  the 
inferior  thyroid  artery,  which  separates  it  from  the  verte- 
bral :  the  sympathetic  nerve  and  its  branches  descending, 
and  the  recurrent  nerve  ascending,  and  some  loose  areolar 
tissue  lie  also  behind  the  common  carotid,  and  sej^arate 
it  from  the  spine  and  longus  colli  muscle. 


COMMON  CAROTID  ARTERIES.  77 

First  or  inferior  stage  of  the  left  Common  Carotid. — 
The  left  carotid  artery  arises  from  the  arch  of  the  aorta. 
The  first  stage  of  this  artery  may  be  divided  into  two 
portions, — ^a  thoracic  and  cervical:  the  thoracic  extends 
from  the  origin  of  the  vessel  from  the  arch  of  the  aorta, 
between  the  origins  of  the  arteria  innominata  and  left 
subclavian,  and  opposite  to  the  second  dorsal  vertebra, 
to  the  upper  and  back  part  of  the  left  sterno-clavicular 
articulation.  This  portion  is  therefore  situated  within 
the  cavity  of  the  thorax.  Anteriorly,  its  origin  is  covered, 
by  the  sternum,  sterno-clavicular  articulation,  sterno- 
hyoid and  ster no- thyroid  muscles,  and  the  commence- 
ment of  the  left  vena  innominata;  and  higher  up,  in  its 
second  or  cervical  portion,  it  has  the  same  anterior  rela- 
tions as  the  artery  of  the  right  side.  Internally  it  is 
related  to  the  arteria  innominata,  trachea,  oesophagus, 
and  thymus  gland  which  usually  overlaps  it.  In  close 
relation  to  it  externally  v^Q^xidi  the  internal  jugular  vein, 
and  the  pneumogastric  nerve,  which  lies  concealed  deeply 
between  the  artery  and  the  vein )  the  phrenic  nerve,  and 
the  upper  part  of  the  left  pleura  and  lung  are  also  related 
to  its  outer  side  :  the  thoracic  duct  lies  posterior  to  the 
artery  at  its  origin,  but  afterwards  passes  to  its  external 
side.  Posteriorly^  it  first  rests  on  the  left  _side  of  the 
trachea,  and  on  the  oesophagus,  and  afterwards  upon 
parts  similar  to  those  which  constitute  the  posterior  rela- 
tions of  the  right  common  carotid.  Higher  up  it  is 
separated  from  the  spine  and  longus  colli  muscle  by  the 
sympathetic  nerve  and  its  cardiac  branches,  as  at  the 
right  side.  These  are  the  usual  relations  of  the  left 
carotid,  but  they  may  vary,  or  their  number  be  increased 
in  consequence  of  irregularities. 

Hence  it  appears  that  the  right  and  left  common 
carotids  difi'er  in  the  following  respects  in   their  first 

stage.     The  right  comes  from  the  arteria  innominata, 

7* 


78  COMMON    CAROTID   ARTERIES. 

and  the  left  from  the  arch  of  the  aorta;  consequently 
the  left  is  longer  than  the  right.  The  left  lies  within 
the  cavity  of  the  thorax^  on  the  front  of  the  trachea  and 
cesaphagus,  and  is  intimately  connected  with  the  tho- 
racic duct.  On  the  right  side  the  internal  jugular  vein 
separates  from  the  artery  inferiorly,  passing  outwards 
from  its  external  surface ;  a  small  vascular  triangle  is 
thus  formed,  bounded  internally  by  the  carotid  artery, 
externally  by  the  internal  jugular  vein,  and  inferiorly  by 
the  first  stage  of  the  subclavian  artery.  On  the  left  side 
the  jugular  vein  overlaps  the  outer  edge  of  the  carotid 
artery  inferiorly,  so  that  no  such  vascular  triangle  exists. 
The  student  should  now  examine  the  large  venous 
trunks  which  are  related  to  the  thoracic  portion  of  the 
left  carotid  artery.  The  left  internal  jugular  vein  will 
be  seen  descending  along  the  outer  side  of  the  artery, 
and  in  this  situation  uniting  with  the  left  subclavian 
vein  to  the  right  side  of,  and  on  a  plane  anterior  to,  the 
left  subclavian  artery,  to  form  the  left  vena  innominata. 
When  the  jugular  vein  is  distended  it  overlaps  the  outer 
part  of  the  left  common  carotid  artery  in  this  situation. 
The  origin  of  the  left  vena  innominata  will  be  therefore 
anterior  to  a  point  corresponding  to  the  narrow  inter- 
space between  the  lower  parts  of  the  thoracic  portions 
of  the  left  carotid  and  subclavian  arteries:  it  then 
passes  obliquely  in  front  of  the  left  common  carotid,  the 
trachea  and  arteria  innominata,  and  unites,  as  already 
described,  with  the  right  vena  innominata  to  form  the 
vena  cava  descendens.  In  its  course  the  left  vena  inno- 
minata receives  the  inferior  thyroid,  the  left  internal 
mammary,  left  phrenic,  pericardial,  and  anterior  medi- 
astinal veins.  The  left  vena  innominata  is  retained  in 
its  position  by  a  thin  layer  of  the  descending  portion  of 
the  thoracic  fascia. 


COMMON   CAROTID    ARTERIES.  79 

Second  or  superior  stage  of  the  common  carotid  artery. 
—In  this  stage  the  artery  of  each  side  lies  close  to  the 
bodies  of  the  cervical  vertebrae,  resting  posteriorly  on  the 
longus  colli  muscle  and  symi)athetic  nerve ;  internally  it 
is  related  to  the  larynx,  pharynx,  and  thyroid  gland  : 
externally  its  relations  are  the  same  as  in  the  inferior 
stage.  In  front  it  is  covered  by  the  integuments,  pla- 
tysma  myoides,  and  cervical  fascia :  the  sterno-mastoid 
branch  of  the  superior  thyroid  artery  crosses  it  ante- 
riorly, whilst  the  superior  thyroid  itself  descends  on  a 
plane  anterior  and  internal  to  it. 

The  common  carotid  artery  will  be  found  related  to 
two  triangularregions  in  the  neck, — namely,  the  anterior 
inferior,  and  the  anterior  superior  :  the  first  is  bounded 
internally  by  the  middle  line,  which  may  be  considered 
as  the  base ;  the  two  other  sides  are  situated  externally, 
— the  lower  side  formed  by  the  external  origin  of  the 
sterno-cleido-mastoid  muscle,  and  the  upper  by  the 
anterior  belly  of  the  omo-hyoid;  the  apex  is  situated 
externally  at  the  decussation  between  these  two  mus- 
cles. The  carotid  artery  will  be  seldom  found  contained 
fairly  within  this  triangular  region;  in  an  emaciated 
subject  a  small  portion  of  the  vessel  may  lie  within  it, 
corresponding  to  the  apex;  but  in  a  muscular  subject  the 
artery  lies  under  cover  of  the  sterno-mastoid  muscle, 
until  it  has  passed  into  the  anterior  superior  lateral 
triangle.  This  latter  space  is  bounded  superiorly  by 
the  posterior  belly  of  the  digastric  and  the  stylo-hyoid 
muscles;  this  may  be  considered  the  base:  externally 
by  the  sterno-mastoid  muscle,  and  internally  by  the 
anterior  belly  of  the  omo-hyoid  :  the  apex  is  situated 
infcriorly  at  the  point  of  separation  between  these  two 
muscles. 

It  would  appear  from  the  preceding  account  that  the 
trunk  of  the  common  carotid  artery  may  be  effectually 


80 


COMMON    CAROTID   ARTERIES. 


compressed  against  the  spinal  column,  so  as  to  prevent 
hemorrhage  in  case  of  a  wound  of  the  trunk  or  its 
branches.  Such  pressure,  however,  could  not  in  a  great 
majority  of  cases  be  maintained  sufficiently  long  in  con- 

Fig.  1.— Dissection  to  show  part  of  the.  course  of  the.  External  Carotid  Artery,  of  some 
of  its  branches,  and  part  of  the  course  of  the  right  Subclavian  Artery. 


1,  Occipital  portion  of  Occipito-frontalis-  Muscle.  2,  Insertion  of  Sterno-niastold  Muscle— aponeu- 
rotic connection  between  it  and  TrajK'zius  removed.  3,  Lolje  or  Lobulus  of  the  Eiir.  4,  Ramus  of 
the  lower  jaw.  5,  Masseter  Muscle.  6.  Upper  portion  of  Trapezius  Muscle.  7,  Splenius  Muscle. 
8,  Levator  Anguli  Scapul*.  9,  Steruo-mastoid.  10,  Great  Coruu  of  the  Os-hyoides,— the  Lingual 
Artery  getting  above  it  to  pass  deeper  tlian  the  Hyo-glossus  Muscle.  11,  Mylo-hyoid  Muscle. 
12,  Anterior  belly  of  Digastric  Muscle— the  posterior  has  been  removed.  13.  Lower  part  of  Trapezius. 
14,  Scalenus  Medius  and  Posticus.  15,  Relation  between  the  Omohyoid  and  Sternomastoid  Muscles. 
16,  Anterior  belly  of  the  Omohyoid.  17.  Posterior  belly  of  Omohyoid.  18,  One  of  the  Nerves  of  the 
Brachial  Plexus.  19.  Posterior  Scapular  Artery  given  off  in  this  case  by  Subclavian  Artery  behind 
Anterior  Scalenus.  20,  Anterior  Scalenus  Muscle.  21,  Portion  of  clavicular  origin  of  Sterno  mas- 
toid. 22,  Sternal  origin  of  Sterno-mastoid  Muscle.  23.  Thyroid  Gland.  24,  Aponeuiotic  junction 
between  the  Trapezius  and  Deltoid  Muscles.  25,  Clavicle.  26.  Deltoid  Muscle.  27,  Small  Arterial 
twig.  Lower  A.  Bifurcation  of  Common  Carotid  Artery.  Upper  A,  External  Carotid  Artery. 
B,  Subclavian  Artery  after  having  passed  behind  the  Anterior  Scalenus  Muscle,  a,  Superior  Thyroid 
Artery,  b.  Facial  or  External  Maxillary  Artery  :  Submaxillary  Gland  removed.  The  Inferior  Pala- 
tine Artery  is  seen  behind  b.  c.  Interior  Mental  or  Submental  Artery,  d,  Transversalis  Faciei 
Artery,  e.  External  Carotid  near  its  termination  :  lower  part  of  Parotid"  Gland  removed,  f,  Supra- 
scapular Artery  crossing  the  Anterior  Scalenus  Muscle. 


sequence  of  the  great  suffering  produced  by  pressure  on 
the  adjacent  nerves;  still  it  is  often  of  the  greatest 
importance  to  know  a  means  of  arresting  the  flow  of 
blood,  until  the  surgeon  shall  be  in  attendance  to  per- 
form the  operation  of  tying  the  w^ounded  artery. 


VEINS   or   THE    NECK. 


81 


Fig.  8. — Dissection  to  sliow  the  relations  of  the  Nerves,  Arteries,  and  Veins  of  the 
right  side  of  the  neck. 


A,  Arteria  Innoniinata.  B,  Subclavian  Artery  crossed  by  the  "Vagus  Nerve.  C,  Common  Carotid 
Artery  having  the  Vagus  Nerve  to  its  outside.  D,  K,  Exteruul  Carotid  Artery.  F,  F,  Internal 
Jugular  Vein  crossed  by  branches  of  the  Cervical  Plexus,  which  join  the  Desccndens  Noni  Nerve. 
G,  Facial  Artery.  H,  Occipital  Artery  in  relation  with  Internal  Jugular  Vein,  and  Ninth  Nerve. 
I.Superior  Thyroid  Artery.  K,  Subclavian  Artery  in  relation  with  Brachial  Plexus  of  Nerves. 
L,  Part  of  Subclavian  Vein  lying  on  Scalenus  Anlicus  Muscle.  M.  Transversalis  Colli  Artery, 
O,  Union  of  F.xternal  Jugular  and  Posterior  Scapular  Veins.  P,  Transversalis  Humeri  Artery. 
Q,  Q,  Q,  Branches  of  Brachial  Plexus  of  Nerves.  R.  R,  Omo-hyoid  Muscle.  S,  Trapezius  Muscle. 
T,  Clavicle.  V,  Clavicular  origin  of  Sterno-mastoid  Muscle.  Y,  Scalenus  Posticus  Muscle.  Z,  Sple- 
nius  Muscle,  a.  Cervical  Plexus  assisting  in  forming  the  Phrenic  Nerve  which  descends  on  the 
Scalenus  Anticus  Muscle,  b.  Spinal  Accessory  Nerve,  which  pierces  the  Sterno-mastoid  Muscle, 
c.  Internal  Carotid  Artery,  with  Descendens  Noni  Nerve  lying  on  it.  d,  Vagus  Nerve  between  the 
Carotid  Artery  and  Internal  Jugular  Vein,  e,  Ninth  Nerve,  f.  Lingual  Artery  passing  under  the 
Hyo-glossus  Muscle,  g,  Mastoid  portion  of  Sterno-mastoid  Muscle,  h,  Genio-hyoid  Muscle,  i,  Mylo- 
hyoid Muscle  cut  and  turned  forwards.  I,  Internal  Maxillary  Artery  passing  behind  the  neck  of  tlio 
lower  jaw.  m,  Sterno-thyroid  Muscle  cut  across,  n,  Sterno-hyoid  Muscle  cut  across,  p,  Sympa- 
thetic Nerve  behind  and  between  Carotid  Artery  and  Jugular  Vein,    r,  Parotid  Duct. 


82  VEINS   OP   THE   NECK. 


VEINS   OP   THE   NECK. 


Before  we  proceed  to  speak  of  the  operation  of  tying 
the  trunk  of  the  common  carotid  artcrj^,  the  student  is 
advised  to  study  the  anatomy  of  the  large  veins  of  the 
neck.  The  External  Jugular  Vein  will  be  seen  com- 
mencing behind  and  close  to  the  angle  of  the  lower  jaw, 
and  to  the  anterior  border  of  the  sterno-mastoid  muscle : 
it  is  in  fact  a  continuation  of  the  temj)oro-maxillary 
vein:  it  then  crosses  the  sterno-mastoid,  running  ob- 
liquely downwards  and  backwards,  and  covered  by  the 
platysma-myoides  muscle,  until  it  reaches  about  the 
centre  of  the  clavicle;  it  then  sinks  behind  and  under- 
neath the  posterior  border  of  the  sterno-mastoid  and 
terminates  in  the  subclavian  vein.  It  pierces  the  cer- 
vical fascia  in  two  situations, — at  its  origin  near  the 
angle  of  the  jaw,  and  at  its  termination  above  the 
clavicle.  In  its  intermediate  course  it  is  situated  imme- 
diately under  cover  of  the  platysma,  and  is  compara- 
tively superficial.  Sometimes  a  large  branch  of  commu- 
nication will  be  seen  passing  from  the  external  to  the 
internal  jugular  vein  below  the  angle  of  the  jaw,  and 
close  to  the  sub-maxillary  gland.  Along  the  anterior 
border  of  the  sterno-cleido-mastoid  muscle,  a  large  vein, 
the  Anterior  Jugular,  will  be  observed  passing  down 
towards  the  sternum  and  covered  by  a  portion  of  the 
cervical  aponeurosis:  it  lies. in  front  of  the  sterno-hyoid 
muscle,  and  close  to  the  upper  margin  of  the  sternum 
it  passes  outwards  behind  the  sterno-cleido-mastoid 
muscle,  runs  for  a  short  distance  along  the  upper  and 
back  part  of  the  clavicle  across  a  space  filled  with  loose 
areolar  tissue,  situated  between  the  lower  part  of  the 
sterno-mastoid  muscle  anteriorly  and  the  insertion  of 
the  scalenus  anticus  posteriorly,  and  finally  terminates 
in  the  subclavian  vein  internal  to  the  entrance  of  the 


LIGATURE    OF    THE    COMMON    CAROTID.  83 

external  jugular  vein,  or  in  common  with  this  vessel :  a 
transverse  branch  of  communication  will  sometimes  be 
found  connecting  the  two  anterior  jugular  veins  imme» 
diately  above  the  sternum. 

The  Internal  Jugular  Vein  should  be  carefully  studied 
in  relation  to  the  common  carotid  artery  of  each  side. 
These  vessels  are  contained  within  a  sheath  formed  by 
the  cervical  aponeurosis,  and,  as  has  been  already  stated, 
the  vein  lies  upon  the  outer  side  of  each  of  the  common 
carotid  arteries  in  their  two  cervical  stages:  there  is, 
however,  at  the  lower  portion  of  the  artery  of  the  left 
side,  a  closer  connection  between  it  and  the  internal  jugu- 
lar vein  than  at  the  right.  Frequently  a  well-marked 
aj^oneurotic  septum  will  be  found  running  from  the  an- 
terior to  the  posterior  portion  of  the  sheath,  so  as  to 
divide  it  into  two  canals,  the  inner  containing  the  artery, 
the  outer  containing  the  vein  and  vagus  nerve. 

LIGATURE  OF  THE  COMMON  CAROTID  ARTERY. 

This  operation  has  been  performed  on  several  occa- 
sions, and  under  various  circumstances.  The  four  fol- 
lowing heads  will  include  these  different  operations : — 

1.  The  common  carotid  has  been  tied  for  wounds  or 
ulceration  of  this  vessel  or  of  its  branches. 

2.  It  has  been  tied  according  to  the  Huntcrian  method, 
i.e.  between  the  aneurismal  tumor  and  the  heart,  in  cases 
of  aneurism  of  the  trunk  of  the  artery  itself,  or  of  its 
branches. 

3.  The  artery  has  been  tied  according  to  the  method 
proposed  by  Brasdor  and  Dessault,  i.e.  beyond  the  aneu- 
rismal tumor, — between  it  and  the  capillary  system  of 
vessels, — for  the  cure  of  aneurism  of  the  trunk  of  the 
artery  itself. 

4.  Upon  the  same  principle  as  that  adopted  by  Bras- 
dor,  the  common  carotid  has  been  tied  beyond  the  tumor, 


84 


LIGATURE    OP    THE    COMMON    CAROTID. 


in  cases  of  aneiirismal  disease  of  the  arteria  innominata, 
including  the  origin  of  the  right  carotid.  This  plan  was 
first  recommended  by  Mr.  Wardrop. 

That  the  direct  flow  of  blood  through  the  common 
carotid  artery  may  be  arrested  without  impairing  the 

Fig.  Q.—Left   Common  Carotid  dividing  into  the  External  and  Internal  Carotid 

Arteries. 


J' -'iiAllto* 


1.  Common  Carotid  Artery.  2,  Internal  Carotid.  3,  External  Carotid.  4,  Superior  Thyroid.  5,  Lin- 
gual. 6,  Pharyngeal  Artery.  7,  Facial.  8,  Inferior  Palatine  and  Tonsillar  Arteries.  9,  Submaxillary. 
10,  Submental.  11,  Qccipital.  12,  Posterior  Auricular.  13,  Paiotid  branches.  14,  Internal  Maxillary. 
15.  Temporal  Artery.  16,  Subclavian  Artery.  17,  Axillary,  18,  Vertebral  Artery.  19,  Thyroid  Axis. 
20,  Inferior  Thyroid  giving  off  the  Ascending  Cervical.  21,  Transverse  Cervical.  22,  Supra-scapular. 
23,  Internal  Mammary  Artery. 

functions  of  the  brain,  has  been  abundantly  proved  by 
dissection.  In  a  man  who  died  seven  years  after  aneu- 
rism of  the  neck,  Petit  found  the  common  carotid  oblite- 
rated. Holier  has  noticed  a  similar  occurrence.  Baillie 
found  it  obliterated  on  one  side  and  contracted  on  the 


LIGATURE    OF   THE    COMMON    CAROTID.  85 

other,  and  Jadelot  is  said  to  have  observed  a  case  in 
which  both  common  carotids  were  obliterated.  By  the 
experiments  of  Galen  and  Valsalva  upon  dogs,  and  by 
the  success  of  the  operation  on  the  human  subject,  the 
same  fact  has  been  demonstrated.  This  will  not  aj^pear 
surprising,  if  we  recollect  that  the  brain  is  supplied  by 
four  large  arteries,  viz. : — the  two  internal  carotids,  and 
the  two  vertebrals  arising  from  the  subclavian  arteries, 
and  that  these  anastomose  in  the  freest  manner  by  large 
branches  at  the  base  of  the  brain,  independently  of  their 
extensive  communication  by  smaller  branches.  Mr. 
Hodgson  is  inclined  to  believe  that  the  brain,  in  its 
natural  state,  receives  a  larger  quantity  of  blood  than 
is  requisite  for  the  due  performance  of  its  functions; 
having  found  that  in  a  dog  whose  two  carotids  had  been 
tied,  the  aggregate  of  the  anastomosing  tubes  was  not 
equal  to  the  calibre  of  one  carotid  artery  in  its  natural 
state. 

The  trunk  of  the  common  carotid  has  been  tied  in 
cases  of  wound  or  ulceration  of  this  vessel  or  of  its 
branches.  Hebenstreit  relates  the  first  case  on  record 
in  which  it  was  tied  in  the  human  subject,  in  conse- 
quence of  its  having  been  divided  during  the  removal  of 
a  schirrous  tumor:  the  operation  succeeded.  In  a  second 
case  Mr.  Abernethy  tied  the  common  carotid  for  hemor- 
rhage from  a  lacerated  wound:  and  though  the  patient 
did  not  recover,  yet  his  death  was  not  occasioned  by  an 
insufficient  quantity  of  blood  being  transmitted  to  the 
brain.  My  colleague,  Mr.  Ellis,  one  of  the  surgeons  of 
the  Jervis  Street  Hospital,  tied  this  artery  with  complete 
success*  in  an  individual  who,  in  an  attempt  to  commit 
suicide,  had  opened  some  of  the  branches  of  the  artery 
by  an  incision  which  extended  from  the  angle  of  the  jaw 

*  Ellis's  Clinical  Surgery,  p.  26. 


86  LIGATURE    OF   THE    COMMON   CAROTID. 

towards  the  chin.  Sir  A.  Cooper  was  the  first  who  tied 
the  artery  for  the  cure  of  aneurism,  according  to  the 
Hunterian  method,  and  this  operation  has  since  been  re- 
peatedly performed,  and  with  considerable  success.  The 
same  operation  has  also  been  performed  for  aneurism  by 
anastomosis  of  the  orbit,  by  Travers  and  Dalrymple.  It 
was  also  tied  successfully  by  Professor  Pattison,  for  a 
large  aneurism  by  anastomosis  of  the  cheek  ;*  and  both 
common  carotids  were  tied  successfully  by  Dr.  Mussey, 
of  New  Hampshire  in  America,  for  aneurism  by  anasto- 
mosis on  the  crown  of  the  head  :f  between  the  two  opera- 
tions there  was  an  interval  of  only  twelve  days:  the 
tumor  was  subsequently  removed,  and  the  patient  re- 
covered. It  has  been  observed  that  when  this  vessel  is 
the  seat  of  aneurism,  it  frequently  occurs  at  its  bifurca- 
tion, where  there  exists  even  in  health  a  transverse 
dilatation. 

The  02)eration  of  tying  the  common  carotid  artery 
beyond  the  aneurismal  tumor,  i.e.  at  the  capillary  side 
of  the  aneurism,  has  been  performed  by  Deschamps  and 
Sir  A.  Cooper,  but  with  fatal  results.  In  1825  Mr. 
Wardrop  performed  this  operation  with  success.J  The 
common  carotid  has  also  been  tied  in  accordance  with 
the  proposal  of  Mr.  Wardrop.  Acting  on  the  suggestion 
of  Mr.  Wardrop,  Mr.  Evans  of  Derbyshire  tied  the  artery 
in  a  caseof  aneurism  of  the  arteriainnominata involving 
the  origin  of  the  right  common  carotid ;  this  operation 
was  successful.§  This  vessel  was  also  tied  for  aneurism 
of  the  arteria  innominata  by  Dr.  Hutton,  one  of  the 
surgeons  of  the  Eichmond  Hospital,  in  June,  1842 :  the 


*  Med.  and  Phys.  Jour.  vol.  48. 

t  Amer.  Jour.  Med.  Sciences  for  February,  1830. 

X  Trans,  of  Med.  Chir.  Soc,  1825. 

d>  Lancet,  1828. 


LIGATURE   OP   THE   COMMON    CAROTID.  87 

jDatient  died  on  the  seventy-sixth  day.  There  was  no 
union  of  the  coats  of  the  artery  where  the  ligature  had 
been  appUed.* 

This  artery  has  been  tied  about  eleven  times  for  aneu- 
rism of  the  arteria  innorainata,  upon  the  principle  advo- 
cated by  Mr.  Wardrop.  Two  out  of  the  eleven  recovered; 
the  rest  died. 

TJie  operation  of  including  the  Common  Carotid  Artery 
in  a  ligatwe  may  be  performed  either  in  its  inferior  stage 
below  the  omo-hyoid  muscle,  or  in  its  superior  stage, 
above  this  musclei. 

The  operation  of  tying  the  Common  Carotid  Artery  in  its 
inferior  stage.  An  incision  should  be  made  through  the 
integuments  along  the  internal  margin  of  the  sterno- 
mastoid  muscle,  for  the  extent  of  about  three  inches 
above  the  clavicle.  In  most  cases  a  vein  may  be  ob- 
served descending  along  the  anterior  margin  of  the 
sterno-mastoid  muscle  communicating  with  the  facial 
vein  above,  and  with  the  thyroid  plexus  of  veins,  or  the 
subclavian  vein,  below:  care  must  be  taken  not  to  injure 
this.  A  portion  of  the  fascia  at  the  lower  part  of  the 
incision  should  next  be  raised  in  the  forceps,  and 
divided  in  a  horizontal  direction :  through  the  opening 
thus  made  a  director  should  be  introduced  from  below 
upwards  in  the  line  of  the  first  incision,  and  the  fascia 
slit  up  on  it  as  far  as  may  be  necessary.  The  lips  of 
the  wound  are  now  to  be  separated  by  retractors,  the 
sterno-mastoid  muscle  being  drawn  outwards,  and  the 
sterno-hyoid  and  sterno-thyroid  inwards.  The  sheath 
of  the  vessels  will  be  thus  exposed,  and  on  the  front  of 
it  may  be  seen  the  internal  branch  of  the  descendens 
noni  nerve,  which  should  be  drawn  inwards,  and  the 
sheath  divided  in  the  same  cautious  way  as  the  fascia. 

*  Dublin  Pathological  Reports,  1842,  p.  107. 


88  LIGATURE    OF   THE    COMMON    CAROTID. 

A  ligature  is  now  to  be  passed  round  the  artery,  direct- 
ing the  needle  from  without  inwards,  in  order  to  avoid 
the  jugular  vein,  which  sometimes  suddenly  swells  out 
during  ex^^iration,  and  then  contracts  during  inspiration. 
As  the  vein  fills  at  both  its  upper  and  lower  extremit}^, 
an  assistant  should  in  such  case  compress  it  both  at  the 
upper  and  lower  angle  of  the  wound.  In  very  many 
cases  the  vein,  so  far  from  giving  any  trouble,  is  not 
even  observed  during  the  whole  of  the  operation.  In  a 
case  operated  on  by  Dr.  Browne,  of  the  Navan  County 
Infirmary,  'Hhe  internal  jugular  vein  did  not  appear, 
nor  was  it  a  source  of  the  slightest  inconvenience 
during  the  operation."  In  a  similar  case  related  by  Mr. 
Hodgson,  "  the  jugular  vein  affbrded  no  trouble  in  the 
operation ;  it  was  not  even  seen."  Mr.  Eead,  of  Dublin, 
whose  experience  is  very  considerable,  is  reported  by 
Mr.  Hargrave  to  have  said  that  "  in  all  the  operations 
he  performed,  or  assisted  in,  on  this  vessel,  the  vein  was 
not  found  to  interfere  with  the  operation,  nor  was  it 
even  seen."*  The  existence  of  the  fibrous  septum 
extending  from  the  anterior  to  the  j)Osterior  part  of  the 
sheath,  and  thus  separating  the  artery  from  the  vein, 
may  explain  this  fact.  Care  is  to  be  taken  to  avoid 
including  the  pneumogastric  nerve,  w^hich  lies  behind 
and  between  the  vessels:  the  nerve  should  be  drawn 
outwards  with  the  vein.  The  sympathetic  and  recur- 
rent nerves  are  behind  the  sheath,  and  there  is  compara- 
tively little  danger  of  including  them  in  the  ligature. 
In  operating  on  the  left  side,  the  proximity  of  the  tho- 
racic duct  is  to  be  borne  in  mind. 

Sedillofs  operation.  He  makes  an  incision  two  and  a 
half  inches  long,  which  passes  from  the  internal  end  of 
the   clavicle   obliquely  upwards   and   outwards   in  the 

*  Operative  Surgery,  p.  68. 


LIGATURE   OP   THE   COMMON    CAROTID.  89 

direction  of  the  interval  between  the  two  origins  of  the 
sterno-deido-mastoid  muscle.  The  skin,  platysma,  and 
deep  fascia  are  successively  divided,  the  two  portions  of 
the  muscle  drawn  apart  with  the  edges  of  the  wound, 
and  the  internal  jugular  vein  is  reached  inside  the  ante- 
rior scalenus  and  phrenic  nerve.  The  sheath  of  the 
vessel  is  opened,  the  vein  drawn  to  the  outside,  and  the 
artery  sought  at  its  internal  side.  The  decided  objec- 
tion to  this  operation  is  that  there  is  the  greatest  pos- 
sible danger  of  wounding  the  internal  jugular  vein, 
which  lies  at  the  bottom  of  this  incision,  and  which,  if 
distended,  as  it  is  most  likely  to  be  during  the  operation, 
from  the  struggles  of  the  patient  or  from  other  causes, 
will  present  itself  in  such  a  manner  as  to  obscure  the 
artery  from  the  view  of  the  surgeon.  In  a  word,  the 
operator,  instead  of  getting  into  that  compartment  of 
the  sheath  which  contains  the  artery,  gets  into  that 
which  contains  the  vein. 

Operation  of  tying  the  Common  Carotid  in  its  superior 
stage.  The  first  incision  should  commence  a  little  be- 
neath the  angle  of  the  lower  jaw,  and  terminate  on  the 
side  of  the  cricoid  cartilage.  This  incision  will  divide 
the  skin,  platysma  myoides,  and  cervical  fascia,  and 
expose  the  sheath  of  the  vessels  with  the  descendens 
noni  nerve  lying  on  its  front.  The  nerve  is  to  be  drawn 
outwards,  and  the  sheath  opened  in  the  cautious  manner 
already  described.  The  artery  being  now  exposed,  the 
needle  is  to  be  carried  around  it  from  without  inwards, 
taking  care  (as  in  the  inferior  operation)  not  to  wound 
the  jugular  vein  nor  include  the  pneumogastric  nerve. 
It  should  also  be  remembered  that  the  communicans 
noni,  a  branch  of  the  cervical  plexus,  not  unfrequently 
descends  w^ithin  the  sheath  of  the  vessels  between  the 
carotid  artery  and  jugular  vein. 

Having  arrived  opposite  the  superior  margin  of  the 
8* 


90  EXTERNAL  CAROTID  ARTERY. 

thyroid  cartilage,  and  below  the  great  cornu  of  the  os 
hyoides,  the  common  carotid  artery  of  each  side  divides 
into  the  external  and  interyial  carotid  arteries.  At  the 
l^oint  of  bifurcation  the  artery  generally  presents  a  trans- 
verse dilatation,  so  that  the  vessel  appears  enlarged  in 
this  situation.  This  enlargement  lies  anterior  to  the 
longus  colli  and  rectus  capitis  anticus  major  muscles, 
corresponding  to  about  the  third  cervical  vertebra,  and 
in  the  adult  to  a  point  about  one  inch  below  the  angle  of 
the  lower  jaAv.  In  old  age,  from  the  absence  of  the 
teeth,  the  angle  of  the  jaw  is  removed  still  farther  above 
the  bifurcation  of  the  common  carotid ;  in  infancy  also, 
before  the  appearance  of  the  teeth,  the  angle  of  the 
lower  jaw  is  situated  at  a  comparatively  considerable 
distance  above  the  division  of  the  common  carotid  artery. 

EXTERNAL   CAROTID   ARTERY. 

This  artery  usually  arises  nearly  opposite  the  superior 
margin  of  the  thyroid  cartilage;  it  is  situated,  until 
crossed  by  the  digastric  and  stylo-hyoid  muscles,  in  the 
anterior  superior  lateral  triangle  of  the  neck.  It  derives 
its  name,  not  from  its  position  with  regard  to  the  inter- 
nal carotid  at  the  origin  of  these  vessels  from  the 
common  trunk,  for  in  this  situation  the  external  carotid 
is  the  more  internal  of  the  two,  but  because  its  ultimate 
destination  is  to  those  ]5art8  external  to  the  cranium, 
whilst  the  destination  of  the  internal  carotid  is  princi- 
pally to  the  parts  contained  within  this  cavity.  The 
external  carotid  may  be  divided  into  two  stages,  the 
first  extending  from  its  origin  to  the  lower  part  of  the 
parotid  gland;  and  the  second  where  the  artery  lies 
within  the  substance  of  this  gland.  After  its  origin  it 
ascends  towards  the  sub-maxillary  gland,  but  afterwards 
turns  outwards,  and  plunges  into  the  parotid  gland, 
through  which  it  ascends  as  far  as  the  neck  of  the  in- 


EXTERNAL  CAROTID  ARTERY.  91 

ferior  maxillary  bone,  where  it  terminates  by  dividing 
into  the  temporal  and  internal  maxillary  arteries.  In 
this  course  it  describes  a  curvature,  the  convexity  of 
which  looks  upwards,  backwards,  and  inwards  towards 
the  tonsil.     In  its  first  stage,  before  it  reaches  the  parotid 

Fig.  10. — Tlie  External  Carotid  Artery  and  its  Branches. 


1,  Right  Common  CarotiiJ.  2,  Internal  Carotid.  3,  Kxternnl  Carotid.  4,  Superior  Thyroid.  5, 
Lingual.  6,  Facial.  7,  Submental.  8,  Inferior  Coronary.  9,  Superior  Coronary.  10,  Muscular 
Branches.  11,  Lateral  Nasal  Artery.  12,  Angular  Artery.  13,  Occipital  Artery.  14,  Descending 
Cervical.  15,  Muscular  Branch.  Ifj;  Posterior  Auricular  Artery.  17,  Parotid  Branches.  18,  Inter- 
nal Maxillary.  19,  Temporal.  20,  Transverse  Facial.  21,  Anterior  Auricular.  22,  Supraorbital. 
23,  Middle  Temporal.   24,  Anterior  Temporal.  25,  Posterior  Temporal  Artery. 

gland,  its  cutaneous  surface  is  at  first  comparatively  su- 
perficial, being  covered  b}^  the  skin,  platysma  myoides, 
and  cervical  fascia;  by  the  union  of  the  temporo-max- 
illary  with  the  facial  vein  at  the  commencement  of  the 
external  jugular;  it  is  then  covered  a  little  higher  up  by 


92  EXTERNAL    CAROTID   ARTERY. 

the  posterior  belly  of  the  digastric  inuscle,  the  stylo- 
hyoid muscle,  and  the  hypo-glossal  nerve.  At  its  com- 
mencement it  lies  in  front  of  the  superior  laryngeal 
nerve,  and  the  longus  colli  and  rectus  capitis  anticus 
major  muscles.  On  its  outer  side  we  find  the  internal 
carotid  artery,  internal  jugular  vein,  and  pneumogastric 
nerve.  On  its  inner  side  we  find  the  suj)erior  cornu  of 
the  thyroid  cartilage,  the  posterior  margin  of  the  thyro- 
hyoid ligament,  the  great  cornu  of  os  hyoides,  the  side 
of  the  pharynx,  the  sub -maxillary  gland,  angle  of  the 
jaw,  and  still  more  internally  the  tonsil.  After  it  has 
entered  into  the  substance  of  the  parotid,  it  is  covered 
by  the  skin,  the  j)latysma,  the  cervical  fascia,  a  portion 
of  the  gland,  by  its  corresponding  vein,  namely,  the 
temporo-maxillary,  and  by  the  facial  nerve.  Its  deep 
surface  is  here  separated  from  the  internal  carotid  by  the 
stylo-glossus  and  st^'lo-pharyngeus  muscles,  the  styloid 
process,  or,  when  this  process  is  short,  by  the  stylo-hyoid 
ligament,  the  glosso-pharyngeal  nerve,  and  occasionally 
the  pharyngeal  branch  of  the  pneumogastric  nerve,  and 
part  of  the  gland. 

Operation  of  tying  the  External  Carotid. — The  external 
carotid  may  be  tied  either  above  or  below  the  crossing 
of  the  posterior  belly  of  the  digastric  muscle.  For  the 
latter  purpose  an  incision  should  be  made  through  the 
integuments  and  platysma  myoides,  from  beneath  the 
angle  of  the  jaw  to  the  side  of  the  thyroid  cartilage. 
This  incision  will  expose  the  digastric  muscle,  and  by 
drawing  it  a  little  upwards  the  artery  may  be  exjDOsed 
and  secured  beneath  the  origin  of  its  superior  thyroid 
branch.  Care  should  be  taken  not  to  include  tlie  supe- 
rior laryngeal  nerve,  which  descends  obliquely  inwards 
behind  the  origin  of  the  external  carotid.  Mr.  Guthrie 
is  of  opinion  that  the  ligature  should  be  applied  near  its 
origin,  that  is,  immediately  below  where  the  superior 


SUPERIOR  THYROID  ARTERY.  93 

thyroid  artery  is  given  off.  In  opening  abscesses  of  the 
tonsil  it  should  be  borne  in  mind  that  the  convexity  of 
the  external  carotid  may  be  closely  applied  to  the  out- 
side of  the  swollen  gland. 

The  branches  of  the  external  carotid  artery  are  nine 
in  number,  and  may  be  included  under  the  following 
heads  : — 

Anterior.  Internal,  or  Ascending. 

Superior  Thyroid.  Pharyngea  Ascendens. 

Lingual. 
Facial  or  Labial.  External. 

Transversalis  Faciei. 

Posterior.  Terminating. 

Occii^ital.  Superficial  Temporal. 

Posterior  Auricular.       Internal  Maxillary. 

The  Superior  Thyroid  Artery  arises  opposite  the 
thyro-hyoid  sj^ace.  It  first  ascends  towards  the  os 
hyoides,  and  then  descends  on  the  side  of  the  larynx  on 
a  plane  anterior  and  internal  to  the  external  carotid,  to 
terminate  in  the  thyroid  gland.  In  this  course  it  de- 
scribes a  curvature,  the  convexity  of  which  looks  up- 
wards, touches  the  os  hyoides,  and  corresponds  to  the 
concavity  of  a  similar  curvature  in  the  lingual  artery. 
Posteriorly  it  rests  on  some  areolar  tissue  and  the  supe- 
rior laryngeal  nerve:  anteriorly  it  is  covered  by  the 
integuments,  platysma  myoides,  cervical  fascia,  and  by 
some  small  veins  passing  outwards  from  the  larynx  to 
the  internal  jugular  vein ;  also  by  the  sterno-hyoid,  sterno- 
th3^'oid,  and  omo-hyoid  muscles,  and  an  internal  branch 
of  the  descendens  noni  nerve  which  supplies  the  latter 
muscle. 

The  superior  thyroid  artery  gives  off  the  following 
branches : — 


94  BRANCHES   OF   THE   SUPERIOR   THYROID. 

Hyoidean.  Sterno-Mastoid. 

Sujjerior  Laryngeal.     Inferior  Laryngeal  or  Crico- 
Thyroid. 
Terminating. 

The  Hyoidean  branch,  which  is  small,  passes  inwards 
beneath  the  thyro-hyoid  muscle,  supplies  the  areolar 
tissue  in  this  situation,  and  anastomoses  with  the  cor- 
responding branch  of  the  opposite  side. 

The  Superior  laryngeal  branch  descends  with  the  supe- 
rior laryngeal  nerve,  passes  beneath  the  thyro-hyoid 
muscle,  and  pierces  the  ligament  of  the  same  name. 
Here  it  divides  into  two  branches, — one  of  which  ascends 
behind  the  os  hyoides  to  supj^ly  the  anterior  surface  of 
the  epiglottis  and  mucous  membrane :  the  other  de- 
scends on  the  inside  of  the  ala  of  the  thyroid  cartilage, 
and  terminates  in  the  crico-arytenoid  and  crico-thyroid 
muscle,  and  by  a  great  number  of  small  branches  in  the 
mucous  membrane  of  the  larynx. 

The  Sterno-mastoid  branch  is  constant,  but  variable  in 
size :  it  crosses  in  front  of  the  sheath  of  the  carotid 
artery  to  reach  the  deep  surface  of  the  sterno-mastoid 
muscle,  in  which  it  is  lost.  This  artery  frequently  arises 
from  the  posterior  part  of  the  external  carotid,  close  to 
the  origin  of  the  lingual ;  from  this  point  it  first  runs 
upwards,  hooks  over  the  lingual  nerve,  Avhich  it  draws 
into  an  angle  salient  downwards;  and  then,  running 
downwards  and  outwards,  it  reaches  the  deep-seated 
surface  of  the  sterno-mastoid. 

The  Inferior  laryngeal  or  crico-thyroid  branch  may  come 
directly  from  the  superior  thyroid,  but  more  usuaHj^  it 
arises  from  its  internal  terminating  branch.  It  passes 
horizontally  inwards  in  front  of  the  crico-thyroid  mem- 
brane, and  along  the  inferior  margin  of  the  thyroid 
cartilage,  to  anastomose  with  its  fellow  of  the  opposite 


BRANCHES    OP   THE    SUPERIOR   THYROID.  95 

side  and  supply  the  crico-thyroid  membrane.  This 
artery  is  pretty  constant,  though  it  varies  as  to  size  and 
origin.  If  it  be  absent  at  one  side,  the  artery  of  the 
opposite  side  will  be  found  larger  than  usual.  It  is  often 
a  branch  of  the  superior  laryngeal. 

When  the  superior  thyroid  artery  arrives  near  the 
thyroid  gland  it  divides  into  four  terminating  or  proper 
thyroid  branches,  namely,  the  internal,  external,  ante- 
rior, and  posterior. 

The  internal  terminating  branch  descends  along  the. 
internal  margin  of  the  corresponding  lobe,  and  unites 
in  forming  an  arch  with  the  corresponding  branch  of 
the  opposite  side :  this  branch  usually  gives  off  the  in- 
ferior laryngeal  artery. 

The  external  terminating  branch  descends  along  the  ex- 
ternal margin  of  the  corresponding  lobe,  and  anastomoses 
with  the  inferior  thyroid. 

The  anterior  terminating  branch  is  distributed  to  the 
anterior  surface  of  the  upper  portion  of  the  gland:  it  is 
not  always  present. 

Lastly,  the  posterior  terminating  branch  descends  be- 
tween the  front  of  the  trachea  and  the  thyroid  gland, 
in  the  substance  of  which  gland  it  is  lost. 

The  superior  thyroid  artery  lies  on  a  plane  anterior 
and  internal  to  the  common  carotid;  and,  therefore,  in 
attempts  at  suicide,  it  is  the  vessel  usually  divided.  In 
this  case,  we  may  either  secure  the  bleeding  vessel,  or 
put  a  ligature  on  the  external  carotid  beneath  the  origin 
of  the  former.  This  artery  has  been  tied  for  the  pur- 
pose of  reducing  the  size  of  a  bronchocele,  or  prepara- 
tory to  extirpating  the  thyroid  gland.  The  incision 
that  exposed  the  external  carotid  will  also  expose  the 
origin  of  the  superior  thyroid.  In  a  case  related  in 
Houston's  Catalogue  (p.  80),  this  vessel  crossed  the 
crico-thyroid  membrane. 


96 


LINGUAL   ARTERY. 


The  Lingual  Artery  is  the  next  in  order,  but,  as  the 
branches  of  the  facial  or  labial  are  more  superficial,  the 
student  will  find  it  expedient  to  dissect  these  first,  and 
afterwards  examine  the  course  and  branches  of  the  lin- 
gual.    This  latter  vessel  arises  a  little  above  the  superior 

Fig.  11 . — Dissection  of  the  Lingual  Artery. 


1,  Frontal  Bone.  2,  Crista  GalH  of  the  Kthmoid  bone.  3,  Sphenoid  Bone.  4,  Sphenoidal  Sinus.  5,  5, 
Vertical  section  of  the  Nose.  6,  Septum  of  Nose,  with  arterial  aniistonioses.  7,  T\>;ig  from  one  of 
the  terminating  branches  of  the  Spheno-palatino  Artery,  descending  through  the  Canal,  O.  8,  Upper 
l.ip.  9,  Soft  Palate,  or  Velum  Pendulum  Palati.  10,  iO,  Branches  of  the  Superior  Palatine  Artery 
which  descend  through  the  Posterior  Palatine  Canal.  11,  Lower  Lip.  12,  The  Tongue.  13,  Lower 
Jaw.  14,  Genio-hyo-glo.ssu3  Muscle.  15,  Hyo-glossus  Muscle.  16,  Slylo-glossus  Muscle.  17,  Genio- 
hyoid Mu.scle.  18,  Mylo-hyodeus  cut  and  reflected.  19,  Portion  of  Sternohyoid  Muscle.  20,  Pait  of 
the  Omo-hyoid  Muscle.  21,  Thyroid  Cartilage.  22,  Thyro-hyoid  Muscle.  23,  Portion  of  Inferior  Con- 
strictor of  the  Pharynx.  A.  Common  Carotid  Artery,  B,  K,  External  Carotid  Arterv.  C,  Internal 
Carotid,  a,  Superior  Thyroid  Artery  cut.  b,  Superior  Laryngeal  Branch  of  Thyroid,  c.  Lingual 
Artery,  d,  Dorsalis  Linguae,  e,  Hyoidean  Branch  of  Lingual  Artery,  f,  Sublingual  Artery,  g, 
Ranine  Artery  ascending  to  the  base  of  the  Tongue,  h,  Continuation  of  Ranine  Artery,  i.  Facial  or 
External  Maxillary  Artery,  m,  Branch  of  Spheno-palatine  Artery,  n,  Branch  of  Anterior  Ethmoidal 
Artery,    o,  Incisive  Canal. 


thyroid,  and  nearly  opposite  the  os  hyoides :  it  may  be 
divided  into  three  stages :  in  the  first,  it  extends  from  its 
origin  to  the  outer  edge  of  the  hyo-glossus  muscle;  in 
the  second,  it  passes  behind  (or,  more  correctly  speak- 
ing, deeper  than)  the  muscle ;  in  the  third  stage  it  gets 


BRANCHES   Or   THE   LINGUAL.  97 

the  name  of  the  ranine  artery,  and  extends  from  the  in- 
ternal margin  of  the  hyo-glossus  muscle  to  its  termina- 
tion. 

In  i\\Q  first  stage  it  ascends  a  little,  and  then  turns  in- 
wards, to  get  above  the  great  cornu  of  the  os  hyoides, 
making  a  curvature,  the  convexity  of  which  looks  up- 
wards, while  the  concavity,  looking  downwards,  cor- 
responds to  the  convexity  of  the  superior  thyroid  artery, 
from  which  it  is  separated  by  the  extremity  of  the  great 
cornu  of  the  os  hyoides.  In  this  stage  it  corresponds 
posteriorly  to  some  loose  areolar  tissue,  to  the  suj^erior 
larjnigeal  nerve,  and  to  a  small  portion  of  the  middle 
constrictor  of  the  pharynx  at  its  attachment  to  the  great 
cornu  of  the  os  hj^oides :  anteriorly  it  is  covered  by  the 
integuments,  platysma  myoides,  cervical  fascia,  lym- 
phatic glands,  and  some  small  veins.  The  lingual  nerve 
lies  suj^erficial  and  superior  to  the  artery,  and  sometimes, 
when  the  nerve  descends  a  little  lower  down  than  usual, 
it  touches  the  artery :  corresponding  to  the  first  stage 
of  the  course  of  the  lingual  artery,  the  tendon  of  the 
digastric  may  be  seen  lying  suj^erior  to  the  lingual 
nerve;  so  that  from  above  downwards  in  this  situation 
we  find,  first  the  tendon,  secondly  the  nerve,  and  lastly 
the  artery. 

In  the  second  stage  the  artery  passes  upwards  and  in- 
wards, and  frequently  pierces  the  posterior  fibres  of  the 
hyo-glossus  muscle  in  order  to  get  to  its  deep-seated 
surface,  along  which  it  then  passes:  the  hyo-glossus 
thus  separates  the  lingual  artery  from  the  lingual  nerve, 
which  latter  lies  upon  the  cutaneous  surface  of  the  muscle. 
In  this  second  stage  the  artery  at  first  frequently  lies 
superficial  to  a  few  of  the  posterior  fibres  of  the  hj^o- 
glossus  muscle;  these  fibres  have  received  the  name  of 
cerato-glossus  muscle :  afterwards  when  it  gets  to  the 
deep-seated  surface  of  the  hyo-glossus,  it  runs  along  the 


98  BRANCHES   OF   THE   LINGUAL. 

external  surface  of  the  middle  constrictor  of  the  pharynx 
at  its  origin  from  the  great  cornii  of  the  os  hyoides : 
this  portion  jof  the  bone  lies  immediately  below  the  artery, 
and  the  vessel  itself  still  lies  below  the  level  of  the  nerve. 
In  this  situation  the  artery  sends  minute  branches  to 
the  middle  constrictor. 

In  the  third  stage,  where  it  is  sometimes  called  the 
ranine  artery,  it  ascends  a  little  to  reach  the  base  of  the 
tongue,  and  then  proceeds  horizontally  along  the  inferior 
surface  of  this  organ  between  the  genio-glossus  and 
lingualis  muscles,  and  above  the  frsenum  linguae:  here 
it  terminates  in  anastomosing  with  the  artery  of  the 
opposite  side.  In  this  third  stage  it  is  accompanied  by 
the  ninth  nerve,  which  at  the  anterior  edge  of  the  hyo- 
glossus  muscle  turns  under,  that  is,  superficial  to  the 
artery,  and  then  proceeds  along  its  inner  side,  towards 
the  tip  of  the  tongue;  so  that  in  this  situation  the  two 
lingual  nerves  lie  between  the  two  arteries. 

The  branches  given  off  by  the  lingual  artery  are  three 
in  number : 

The  Hyoidean,  Dorsalis  Linguae  and  Sublingual. 

The  Hyoidean  branch  usually  arises  at  the  outer  edge 
of  the  hyo-glossus  muscle  :  it  supplies  the  epiglottidean 
gland,  and  the  muscles  attached  to  the  os  hyoides,  and 
anastomoses  with  the  corresponding  branch  of  the  oppo- 
site side  and  with  the  superior  thyroid  artery. 

The  Dorsalis  linguce  may  be  traced  running  upwards 
and  outwards,  under  cover  of  the  hyo-glossus  muscle, 
towards  the  base  of  the  tongue ;  some  of  its  branches 
are  lost  in  the  stylo-glossus  muscle  and  base  of  the 
tongue  'y  while  others,  ascending,  supply  the  tonsil  and 
velum  palati.  It  lies  immediately  under  the  mucous 
membrane.     In  many  cases  this  artery  is  deficient  or 


LIGATURE   OF   THE   LINGUAL   ARTERY.  99 

diminutive,  and  sometimes  its  place  is  supplied  by  two 
or  three  very  small  branches. 

The  Sublingual  artery  proceeds  forwards  and  out- 
wards to  supply  the  gland  of  the  same  name :  it  also 
sends  branches  to  the  mucous  membrane  of  the  mouth, 
and  often  one  that  pierces  the  mylo-hyoid  muscle  to 
arrive  at  the  anterior  belly  of  the  digastric.  It  anas- 
tomoses with  that  of  the  opposite  side  and  with  the  sub- 
mental artery.  Sometimes  the  place  of  this  artery  is 
supj)lied  by  a  large  branch  from  the  submental,  which 
pierces  the  mylo-hyoid  muscle  to  arrive  at  the  gland. 

Accompanying  Veins.  The  lingual  artery  is  accom- 
panied in  its  first  and  second  stages  by  one  or  two  vence 
comites,  which  arise  from  a  plexus  at  the  base  of  the 
tongue,  and  terminate  in  the  internal  jugular  vein. 
From  the  same  plexus  arises  a  satellite  vein  of  the  lingual 
nerve,  which  accompanies  the  hypo-glossal  or  ninth 
nerve,  and  opens  into  the  facial,  or  into  the  pharyngeal 
vein :  lastly,  the  ranine  vein  lies  on  the  inferior  surface 
of  the  tongue,  superficial  and  external  to  the  artery 
in  its  third  stage,  and  then  passes  between  the  mylo- 
hyoid and  hyo-glossus  muscles  to  terminate  in  the  facial 
vein. 

Operation  of  tying  the  Lingual  Artery.  This  operation 
has  been  proposed  by  Beclard  for  hemorrhage  after 
extirpation  of  portion  of  the  tongue,  or  from  other 
causes.  The  lingual  artery  may  be  exposed  by  an 
incision  extending  transversely  from  the  os  hyoides  to 
the  margin  of  the  sterno-mastoid  muscle.  The  skin, 
platysma,  and  fascia  being  divided,  the  glistening  tendon 
of  the  digastric  muscle  is  brought  into  view:  beneath 
this,  and  lower  down,  is  the  hypo-glossal  nerve,  much 
duller  in  its  appearance  than  the  tendon;  whilst  the 
artery  will  be  found  situated  still  lower  and  a  little^ 
deeper  than  the  nerv^.  ;  J \ J  j  \ ;  :     J  J^ 


100  FACIAL   ARTERY. 

Mr.  Guthrie  advises  that  the  trunk  of  the  external 
carotid  should  be  tied  whenever  there  is  unmanage- 
able hemorrhage  from  its  branches. 

The  ranine  artery  may  be  wounded  in  the  operation 
of  dividing  the  frsenum  linguae.  This  will  not  occur  if 
blunt-pointed  scissors  be  used,  and  their  points  directed 
downwards  during  the  operation.  When  the  artery  is 
wounded  in  the  child,  the  hemorrhage  is  favored  by 
the  vacuum  produced  in  sucking,  and  by  the  heat  and 
mobility  of  the  parts.  As  the  ranine  arteries  anasto- 
mose at  their  extremities  only,  the  right  and  left  sides 
of  the  tongue  may  be  filled  with  different-colored  in- 
jections. It  has  been  proposed  by  Yelpeau  to  puncture 
the  ranine  veins  in  cases  of  glossitis. 

The  Facial  Artery,  called  also  the  labial  or  external 
maxillary,  arises  immediately  above  the  lingual,  and 
often  together  with  it  by  a  common  trunk.  The  artery 
may  be  divided  into  two  stages, — a  cervical  and  a  facial 
stage;  in  its  cervical  stage  it  ascends,  lying  near  the 
outer  surface  of  the  mylo-hyoid  and  hyo-glossus  muscles 
and  under  cover  of  the  skin  and  superficial  fascia,  pla- 
tysma  myoides,  cervical  fascia,  digastric  and  stylo-hyoid 
.muscles,  the  lingual  nerve,  and  portion  of  the  sub- 
maxillary gland,  into  the  substance  of  which  it  pene- 
trates :  in  this  situation  it  lies  under  cover  also  of  the 
body  of  the  inferior  maxillary  bone,  and,  after  passing 
through  the  gland,  touches  the  internal  pterygoid  muscle : 
it  here  makes  a  turn,  the  convexity  of  which  is  directed 
upwards  and  lies  anterior  and  external  to  the  tonsil: 
from  this  point  it  descends,  reaches  the  inferior  margin 
of  the  body  of  the  bone  and  curves  underneath  its  cuta- 
neous surface  where  the  first  stage  terminates.  In  its 
facial  stage  it  ascends  tortuously  from  the  inferior 
flaArgio  of  the  bpdy  of  the  inferior  maxilla,  along  the 
ffiSo  o£  th^  fa;ce,  till  it  arrives^  ai  the  internal  angle  of 


FACIAL   ARTERY. 


101 


Fig.  12.— Dissection  of  some  of  the  terminating  branches  of  the  External  Carotid 
Artery  and  part  of  the  course  of  the  Subclavian  Artery. 


A,  Eight  Subclavian  Artery  in  third  stage.  B,  Internal  Carotid  Artery.  C,  External  Carotid 
Artery.  K,  Temporal  Artery  dividing  lower  down  than  usual,  a,  Supra-scapular  Artery  crossing 
Anterior  Scalenus  Muscle,  b,  Irregular  Posterior  Scapular  Artery  coming  from  Subclavian,  and  in 
this  case  passing  between  branches  of  Brachial  Plexus,  c,  Muscular  Artery,  e,  Superior  Thyroid 
Artery,  f,  Facial  Artery,  g,  Branch  of  Transverse  Arteiy  of  face,  h,  Branch  of  Posterior  Anns 
Artery,  i,  Branch  of  Occipital  Artery.  1,  Anterior  branch  of  Temporal  Artery,  m,  Posterior  branch 
of  Temporal  Artery,  n,  Frontal  Artery.  1,  1,  Pinna.  2,  '2,  Temporal  Muscle  covered  by  Temporal 
Aponeurosis.  3,  Orbicularis  Palpebnrum.  4,  Angular  Artery.  5,  Levator  Labii  Superioris.  6, 
Levator  Anguli  Oris,  or  Musculus  Caninus.  7,  Zygomaticus  Minor.  8,  Zygomaticus  Major.  9,  Orbicu- 
laris Oris.  10,  Muscular  branches  of  Mental  Artery.  11,  Depressor  Anguli  Oris,  or  Triangularis  Oris. 
12,  Buccinator  Muscle.  13,  Parotid  Gland.  14,  Masseter  Muscle.  15,  Steruomastoid  Muscle.  16 
Muscular  branch  of  Occipital  Artery.  17,  Submaxillary  Gland.  18,  Levator  Anguli  Scapulae  Muscle. 
19.  Middle  and  Posterior  Scaleui  Muscles.  20,  Anterior  belly  of  Orao-hyoid  Muscle.  21.  Sterno-thy- 
roid  Muscle.  22,  Sternohyoid  Muscle.  23,  Thyroid  Cartilage.  24,  Trapezius  Muscle.  25,  Posterior 
belly  of  Omo-hyoid  Muscle.  26,  26,  26,  Brachial  Plexus.  27,  Anterior  Scalenus  Muscle.  28,  29, 
Origins  of  Steruo-mastoid  Muscle.    30,  Trachea.    31,  Deltoid.    32,  Pectoralis  Major. 


9* 


102  BRANCHES   OF   THE   FACIAL. 

the  eye,  where  it  terminates  in  anastomosing  with  the 
nasal  and  frontal  branches  of  the  oj^hthalmic  artery. 
In  this  stage  it  lies  on  the  inferior  maxillary  bone,  in  a 
groove  frequently  provided  for  its  reception,  between 
the  masseter  muscle  posteriorly,  and  the  triangularis 
oris  anteriorly:  it  next  lies  on  the  buccinator  muscle, 
the  levator  anguli  oris  or  musculus  caninus,  the  levator 
labii  superioris  proprius;  and,  lastly,  on  the  nasal  division 
of  the  levator  labii  superioris  ala^que  nasi.  In  this  stage 
it  is  covered  by  the  skin  and  superficial  fascia,  platysma, 
and  frequently  by  a  few  of  the  posterior  fibres  of  the 
triangularis  oris  muscle;  by  the  zygomaticus  major  and 
minor,  by  the  labial  division  of  the  levator  labii  supe- 
rioris alseque  nasi  near  its  insertion,  and  finally  by  a 
few  of  the  internal  and  inferior  fibres  of  the  orbicularis 
palpebrarum  muscle.  In  this  situation  the  artery  may 
be  seen,  after  it  has  escaped  from  under  cover  of  the 
labial  portion  of  the  levator  labii  superioris  alaeque  nasi, 
lying  against  the  outer  side  of  the  nasal  portion  of  this 
muscle  and  thus  separating  the  tw^o  portions  from  each 
other. 

The  Facial  Vein  is  much  less  tortuous  than  the  artery, 
and  at  the  root  of  the  nose  and  inner  angle  of  the  eye- 
lids it  communicates  with  the  ophthalmic  and  with  a 
large  vein  that  descends  on  the  middle  line  of  the  fore- 
head, and  communicates  with  its  fellow  of  the  opposite 
side  by  means  of  a  short  branch  which  passes  across  the 
root  of  the  nose:  as  the  facial  vein  descends,  it  crosses 
the  cutaneous  surfixce  of  the  parotid  duct,  being  external 
to  the  artery.  On  the  body  of  the  inferior  maxillary 
bone,  it  lies  close  to  the  artery,  touching  its  outer 
surface:  it  then  descends  superficial  to  the  submaxillary 
gland,  and  either  terminates  in  the  external,,  internal, 
or  anterior  jugular  vein. 


BRANCHES   OF   THE    FACIAL.  103 

The  facial  artery  usually  gives  off  eleven  branches, — 
five  in  its  cervical,  and  six  in  its  facial  stage. 


Branches  of  Cervical  stage.  Branches  of  the  Facial  stage. 

Inferior  Palatine.  Buccal. 

Tonsilitic.  Inferior  Labial. 

Submaxillary.  Inferior  Coronary. 

Inferior  or  Submental.  Superior  Coronary. 

Internal  Pterygoid.       •  Dorsalis  Nasi. 

Angular. 

The  Inferior  Falatine  branch  is  nsuall}^  small:  it  pene- 
trates between  the  stylo-glossus  and  stylo-pharyngeus 
muscles  to  arrive  at  the  superior  and  lateral  part  of  the 
pharynx,  where  it  divides  into  two  principal  branches, 
which  are  distributed  to  the  pharynx,  tonsils,  and  Eus- 
tachian tube. 

The  Tonsilitic  artery  sometimes  comes  off  directly  from 
the  facial,  and  passes  between  the  internal  pterygoid  and 
stylo-glossus  muscles  to  its  destination. 

The  Submaxillary.  As  the  facial  artery  is  passing 
through  the  substance  of  the  submaxillary  gland,  it  gives 
off  several  small  branches,  which  are  distributed  to  this 
structure  and  also  to  the  tongue  and  mucous  membrane 
of  the  mouth. 

The  Inferior  mental^  or  submental  branchy  is  a  larger 
artery  than  the  preceding;  it  runs  along  the  base  of  the 
inferior  maxillary  bone  towards  the  symphisis  menti, 
being  covered  by  the  platysma  myoides,  and  lying  upon 
the  cutaneous  surface  of  the  mylo-hyoid  muscle.  Near 
the  middle  line  it  divides  into  two  branches,  one  of 
which  crosses  in  front  of  the  anterior  belly  of  the  digas- 
tric muscle  to  anastomose  with  that  of  the  opposite  side, 
while  the  other  ascends  on  the  front  of  the  chin  to  sui:)ply 
the  integuments,  and  communicates  with   the  inferior 


104  BRANCHES   OF   THE   FACIAL. 

dental  branch  of  the  internal  maxillary  artery.  In  some 
cases  the  inferior  mental  gives  off  the  sublingual  artery, 
which  more  usually  arises  from  the  lingual. 

The  Internal  Pterygoid  branch.  On  reaching  the  ante- 
rior margin  of  the  internal  pterygoid  muscle  the  facial 
artery  gives  oif  a  small  branch  which  is  distributed  to 
the  substance  of  this  muscle. 

The  artery  in  its  facial  stage  usually  gives  off  the  six 
branches  already  enumerated :  these  may  be  divided  into 
external,  internal,  and  terminating.  The  buccal  and 
some  small  muscular  branches  constitute  the  external; 
the  inferior  labial,  the  two  coronaries,  and  the  dorsalis 
nasi  compose  the  internal,  and  the  angular  is  the  termi- 
nating artery. 

The  Buccal  branch  runs  backwards  from  the  outer  part 
of  the  facial  over  the  buccinator  muscle,  and  then,  getting 
on  the  inside  of  the  ramus  of  the  lower  jaw,  terminates  by 
anastomosing  with  the  internal  maxillary.  Its  branches 
are  distributed  to  the  buccinator  and  masseter  muscles, 
to  the  fat  of  the  cheek,  the  parotid  gland,  and  Steno's 
duct. 

The  Inferior  labial  branch  is  distributed  to  the  muscles 
and  integuments  of  the  lower  lip,  and  anastomoses  with 
the  submental  and  dental  arteries. 

The  Inferior  coronary  artery  passes  inwards  in  a  very 
tortuous  manner  beneath  the  triangularis  oris,  and  quad- 
ratus  menti,  and  proceeds  along  the  margin  of  the  lower 
lip,  close  to  its  mucous  membrane,  where  it  anastomoses 
with  the  artery  of  the  opposite  side.  In  its  course  it 
supplies  the  above-mentioned  muscles,  and  anastomoses 
with  the  inferior  labial,  submental,  and  dental  arteries. 

The  Superior  coronary  artery  arises  near  the  commis- 
sure of  the  lips,  and  runs  tortuously  inwards  between  the 
labial  glands  and  mucous  membrane  of  the  upper  lip. 
On  tbe  middle  line  it  anastomoses  with  the  artery  of  the 


BRANCHES   OF   THE   FACIAL. 


105 


Fig.  13. — Dissection  of  the  anastomosis  between  the  Facial,  Transverse  Facial,  branches 
of  the  Internal  Maxillary,  Ophthalmic,  and  Temporal  Arteries. 


1,  Frontal  portion  of  Occipitofrontalis  Muscle.  2.  2,  Orbicularis  Palpebrarum.  8,  4,  Levator 
Labii  Superioris  Almque  Nasi.  5,  Lev.ttor  Atiguli  Oris.  6,  Zvgoniaticus  Minor.  7,  Zjgomaticus 
Major.  8,  Parotid  Gland.  9.  Masseter.  10,  Small  Artery  to  Buccinator  Muscle.  11,  Depressor 
Anguli  Oris.  12,  12,  Quadratus  Menti  of  each  side.  13,  Orbicularis  Oris.  14,  Artery  of  the  Piltruaa 
coming  off  from  thejunction  of  the  Superior  Coronaries.  K,  Ascending  branch  of  Submental  Artery. 
P.  P,  P,  P,  Palpebrse.  a.  Frontal  Artery,  b,  b,  c,  c,  Branches  of  Temporal  Artery,  the  upper  branch 
Bnastomo«!ing  with  a  branch  of  the  Frontal  Artery,  d,  Transversalis  Faciei  Artery,  e,  e,  Facial  or 
External  Maxillary  Artery,  f.  Twig  to  Ma.ssetcr  Muscle,  g,  Inferior  Coronary  Artery,  h,  Superior 
Coronarv  Artery,  i,  Anastomosis  between  the  Nasal  branch  of  the  Ophthalmic  and  Angular  Arte- 
ries. 1, "Inferior  Labial  Artery,  m.  Facial  Artery  giving  off  Superior  Coronary  Artery,  n,  Infra- 
orbital Artery,    o,  Portion  of  Corrugator  Supercilii  Muscle. 


106  BRANCHES   OP   THE   FACIAL. 

opposite  side,  and  sends  upwards,  towards  the  septum  of 
the  nose,  a  small  branch  termed  the  artery  ofthefiltrum, 
the  branches  of  which  are  distributed  to  the  muscles, 
integuments,  and  mucous  membrane  of  the  upper  lip  and 
to  the  gums,  where  these  small  vessels  anastomose  with 
branches  of  the  inferior  dental  artery. 

The  Dorsalis.  or  lateralis  nasi  artery^  ascends  obliquely 
inwards,  and  lies  on  the  outer  surface  of  the  nasal  por- 
tion of  the  levator  labii  superioris  ala)que  nasi  muscle, 
and  distributes  its  branches  to  the  muscles,  cartilages, 
and  integuments  of  the  nose  -,  after  which  it  anastomoses 
with  the  artery  of  the  opposite  side.  Some  of  its  minute 
branches  pierce  the  fibro-cartilages  to  reach  the  mucous 
membrane.  We  often  find  the  place  of  this  artery  sup- 
plied by  a  number  of  small  branches;  or,  on  the  contrary, 
there  may  be  a  very  considerable  single  branch,  in  which 
case  the  angular  or  terminating  branch  is  particularly 
small. 

The  Angular  artery  is  the  terminating  branch  of  the 
facial :  it  ascends  between  the  two  portions  of  the  levator 
labii  superioris  alseque  nasi,  and  anastomoses  with  the 
nasal  or  terminating  branch  of  the  ophthalmic  artery. 
When  it  becomes  necessary  to  make  an  incision  into  the 
lachrymal  sac,  it  should  be  made  external  to  the  angular 
artery. 

The  facial  artery  can  be  readily  compressed  or  tied,  as 
it  is  passing  over  the  body  of  the  inferior  maxillary  bone. 

At  its  origin  this  vessel  is  covered  by  a  few  lymphatic 
glands,  some  of  which  accompany  it  on  the  face:  these 
may  enlarge  and  displace  the  submaxillary  gland  so  as 
to  occupy  its  natural  j^osition.  A  tumor  of  this  kind 
maybe  removed  without  dividing  the  trunk  of  the  facial 
artery;  and  such  has  probably  been  the  nature  of  the 
tumor  in  many  of  those  operations  that  have  been  termed 
extirpation  of  the  submaxillary  gland.    Mr.  Colles  doubts 


OCCIPITAL   ARTERY.  107 

the  possibility  of  removing  it,  on  account  of  its  connec- 
tion with  the  facial  artery,  and  its  dipping  behind  the 
mylo-hyoid  muscle ;  but  a  still  greater  difficulty  arises 
from  its  vicinity  to  the  lingual  nerve,  and  its  intimate 
connection  with  the  gustatory  nerve. 

In  certain  amputations  of  a  portion  of  the  lower  jaw, 
the  artery  is  necessarily  cut  across,  and  care  should  be 
taken  to  divide  it  on  the  bone,  and  not  beneath  it,  lest 
it  should  retract  too  deej^ly  into  the  submaxillary  space. 
Its  coronary  branches  are  divided  in  the  operation  for 
hare  lip;  it  is  not  necessary  to  tie  them,  but  the  suture- 
needle  must  be  passed  sufficiently  deep,  and  near  the 
mucous  membrane,  in  order  to  close  the  posterior  part 
of  the  wound,  as  otherwise  there  might  be  serious 
hemorrhage  into  the  mouth. 

No  artery  presents  greater  varieties  either  as  to  origin, 
termination,  size,  or  relations,  than  the  facial ;  it  some- 
times arises  in  company  with  the  lingual ;  in  many  cases 
it  terminates  by  its  coronary  branches,  and  in  others  by 
the  dorsalis  nasi ;  in  these  cases  the  branches  of  the  facial 
are  replaced  by  those  of  the  transversalis  faciei :  on  the 
other  hand,  according  to  Soemmering,  it  may  extend  to 
the  forehead,  giving  off  the  palj^ebral  and  lachrymal 
arteries.  On  one  side  there  may  be  a  large  facial  artery, 
and  a  mere  rudimentary  artery  on  the  other. 

The  facial  artery  communicates  with  the  internal 
maxillary  by  the  infra-orbital  and  inferior  dental  branches 
of  the  latter,  and  with  the  internal  carotid  by  its  inos- 
culation with  the  nasal  branch  of  the  ophthalmic. 

The  Occipital  Artery  arises  from  the  posterior  part 
of  the  external  carotid,  nearly  02:)posite  to  the  origin  of 
the  lingual  artery :  it  may  be  divided  into  three  stages. 

In  Its  first  stage  it  lies  in  the  anterior  superior  lateral 
triangle  of  the  neck,  running  towards  the  digastric  groove 
of  the  temporal  bone,  and  extends  as  far  as  the  anterior 


108  OCCIPITAL   ARTERY. 

margin  of  the  stern o-mastoid  tnusclC;  passing  obliquely 
over  the  concavity  of*  the  arch  formed  in  the  neck  by  the 
hypo-glossal  nerve,  which  is  therefore  said  to  pass  round 
it.  In  this  stage  the  occipital  artery  at  first  runs  along 
the  inferior  margin  of  the  posterior  belly  of  the  digas- 
tric muscle;  more  posteriorly,  however,  this  muscle 
partly  covers  the  artery,  and  forms  one  of  its  superficial 
relations;  still  more  sujierficially  w^e  find  a  portion  of 
the  parotid  gland,  the  fascia  of  the  neck,  a  few  fibres  of 
the  plat^^sma,  and  the  integuments.  Its  deep-seated  rela- 
tions are  the  internal  carotid  artery,  the  pneumogastric 
nerve,  and  the  internal  jugular  vein,  from  which  last  it 
is  separated  by  the  spinal  accessory  nerve. 

In  its  second  stage  it  passes  somewhat  horizontally  from 
before  backwards,  and  in  its  course  is  covered  by  the  fol- 
lowing parts  : — the  skin  and  a  strong  layer  of  condensed 
areolar  tissue,  the  sterno-mastoid  muscle,  and  behind  this 
by  the  splenius  capitis;  then  deeper,  by  the  trachelo- 
mastoideus  or  complexus  minor,  then  by  the  mastoid 
process  itself,  and  still  deeper  by  the  origin  of  the  poste- 
rior belly  of  the  digastric  muscle.  In  this  stage  the 
artery  is  lodged  in  a  distinct,  but  frequently  superficial, 
groove  in  the  temporal  bone,  internal  to  the  deej)  groove 
for  the  posterior  belly  of  the  digastric,  and  lies  on,  or 
more  correctly  speaking,  external  to  the  outer  margin 
of  the  rectus  capitis  lateralis  muscle,  and  above  the  trans- 
verse process  of  the  atlas;  it  then  passes  across  the  in- 
sertion of  the  obliquus  superior,  and  afterwards  arches 
over  the  insertion  of  the  complexus  major  muscle :  it 
occasionally  lies  underneath  this  muscle. 

In  its  third  stage  it  arrives  at  the  posterior  region  of 
the  neck  by  passing  through  a  condensed  fascia,  which 
unites  the  posterior  margin  of  the  sterno-mastoid  muscle 
with  the  anterior  border  of  the  trapezius  at  their  inser- 
tions, and  then  ascends  obliquely  inwards  and  ramifies 


BRANCHES   OF    THE   OCCIPITAL.  109 

on  the  occipital  region  of  the  head.  In  this  stage  it 
appears  in  the  triangular  space  which  the  splenii  capitis 
muscles  form  by  their  divergence  on  the  middle  line  in 
the  superior  part  of  the  back  of  the  neck,  and  then  as- 
cends on  the  back  of  the  head,  through  the  fibres  of  the 
occipital  muscle,  in  company  with  the  posterior  branch 
of  the  second  cervical  nerve. 

The  occipital  artery  gives  off  the  following  branches : 

Muscular.  Descending  Cervical. 

Posterior  Meningeal.  Mastoidean. 

Terminating. 

The  Muscular  branches  are  distributed  to  the  posterior 
belly  of  the  digastric  muscle,  and  to  the  stylo-hyoid  and 
sterno-mastoid  muscles.  It  occasionally  gives  off  the 
stylo-mastoid  artery,  which  enters  the  stylo-mastoid  fora- 
men and  anastomoses  with  a  branch  of  the  middle  me- 
ningeal from  the  internal  maxillary. 

The  Posterior  Meningeal  branch  arises  from  the  occipi- 
tal as  it  hes  on  the  side  of  the  internal  jugular  vein;  it 
enters  the  foramen  lacerum  posterius,  and  is  distributed 
to  the  dura  mater  in  the  posterior  and  lateral  regions  of 
the  interior  of  the  cranium. 

The  Descending  Cervical  branch  arises  from  the  artery 
as  it  lies  under  cover  of  the  splenius,  near  its  posterior 
margin :  it  sends  branches  to  the  muscles  in  the  imme- 
diate neighborhood,  and  anastomoses  with  the  cervicalis 
suj^erficialis  and  cervicalis  profunda  arteries.  There  are 
sometimes  two  or  even  three  descending  cervical 
branches  present. 

The  Mastoidean  branch,  at  its  origin,  corresponds  to 
the  posterior  surface  of  the  mastoid  process  of  the  tem- 
poral bone;  it  passes  through  the  mastoidean  foramen 
in  this  part  of  the  bone,  accompanied  by  a  vein,  sends 
minute  branches  to  the  mastoid  cells,  and  is  distributed 

10 


110  POSTERIOR   AURICULAR   ARTERY. 

within  the  cranium  to  the  dura  mater  of  the  occipital 
fossae.  As  the  occipital  artery  is  arching  over  the  ob- 
liquus  superior  muscle,  it  communicates  with  the  verte- 
bral artery;  sometimes  it  gives  off  the  stylo-mastoid 
artery. 

The  Terminating  branches  of  the  occipital  artery  ascend 
tortuously  in  the  course  of  the  lambdoidal  suture  to 
supply  the  occij)ito-frontalis  muscle  and  integuments, 
and  to  anastomose  with  the  temporal  and  posterior  au- 
ricular arteries,  and  with  the  occijDital  of  the  opposite 
side.  We  sometimes  find  one  of  those  small  branches 
passing  through  the  j)arietal  foramen  to  be  lost  in  the 
dura  mater. 

Should  it  ever  be  necessary  to  tie  the  occipital  artery 
in  case  of  profuse  hemorrhage  from  any  of  its  branches, 
the  incision  already  recommended  for  exposing  the  ex- 
ternal carotid  will  also  expose  this  vessel  in  the  com- 
mencement of  its  first  stage;  or  an  incision  may  be  made 
along  the  lower  margin  of  the  posterior  belly  of  the 
digastric  muscle,  on  raising  which  the  artery  is  brought 
into  view.  Care  should  be  taken  not  to  injure  or  include 
the  hypo-glossal  nerve. 

The  depth  of  this  artery  behind  the  mastoid  process 
is  very  variable,  and  unless  there  be  a  wound  to  guide 
us  to  the  vessel,  it  is  not  an  operation  that  should  be 
attempted. 

The  Posterior  Auricular  Artery  is  one  of  the 
smallest  branches  of  the  external  carotid :  it  arises  in 
the  substance  of  the  parotid  gland,  nearly  opposite  the 
apex  of  the  styloid  process,  and  ascends  along  the  supe- 
rior margin  of  the  posterior  belly  of  the  digastric  muscle, 
till  it  arrives  at  the  interval  between  the  external  au- 
ditory canal  and  mastoid  process,  where  it  divides  into 
its  two  terminating  branches,  an  anterior  and  posterior 
aural. 


PHARYNGEA   ASCENDENS   ARTERY.  Ill 

The  i:)Ostcrior  auricular  artery  gives  off  the  following 
branches : — 

Stylo-mastoid.     Anterior,  and  Posterior  Aural. 

The  Stylo-mastoid  branch  enters  the  stylo-mastoid 
foramen,  and  after  supplying  the  aqueduct  of  Fallopius, 
the  tympanum  and  semi-circular  canals,  it  terminates  by 
anastomosing  with  a  branch  of  the  middle  meningeal 
artery  which  enters  by  the  hiatus  Fallopii. 

The  Anterior  aural  branch  is  distributed  to  the  internal 
or  deep  surface  of  the  pinna. 

The  Posterior  aural  branch  ascends  between  the  retra- 
hens  auris  muscle  and  bone,  and  supplies  the  integuments 
covering  the  mastoid  process,  and  the  temjioral  and  re- 
trahens  auris  muscles. 

Before  its  bifurcation  the  posterior  auricular  sends 
branches  to  the  parietes  of  the  external  auditory  canal, 
to  the  parotid  gland,  and  to  the  digastric  and  stylo-hyoid 
muscles. 

In  the  operation  of  cutting  down  on  the  facial  nerve, 
in  order  to  remove  a  portion  of  it  after  its  exit  from  the 
stylo-mastoid  foramen,  the  trunk  of  this  artery  must 
have  been  usually  divided,  together  with  its  stylo-mas- 
toid branch. 

Mr.  Harrison  saw  a  case  in  which  it  was  tied  in  front 
of  the  mastoid  process,  for  aneurism  by  anastomosis  on 
the  external  surface  of  the  pinna, — but  without  success. 

The  Pharyngea  Ascendens  Artery  may  be  exposed 
by  the  dissection  recommended  for  exj^osing  the  inter- 
nal carotid,  and  therefore  the  student  would  find  it  more 
expedient  to  defer  its  examination  for  the  present;  he 
may,  however,  study  its  relations  in  the  neck. 

The  pharyngea  ascendens  is  the  first  and  smallest 
branch  of  the  external  carotid.  After  its  origin  it  as- 
cends in  the  neck,  being  related, — posteriorly  to  the  spinal 


112  TRANS VERSALIS   FACIEI   ARTERY. 

column^  the  rectus  anticus  muscle,  and  the  superior 
laryngeal  nerve; — anteriorly  to  the  stylo-pharyngeus 
muscle, — internally  to  the  pharynx,  and  externally  to  the 
superior  cervical,  ganglion  of  the  sympathetic  nerve. 
In  this  course  it  gives  off  a  few  irregular  branches  to 
the  muscles  of  the  pharynx,  and  terminates  by  dividing 
into  two  branches,  the  pharyngeal  and  meningeal. 

The  Pharyngeal  branch  passes  obliquely  upwards  and 
inwards,  and  sends  off  a  number  of  twigs,  some  of  which 
ascend  through  the  superior  constrictor  of  the  pharjmx, 
while  others  descend  in  the  substance  of  the  middle  and 
inferior  constrictors :  they  anastomose  with  branches  of 
the  superior  thj^roid  and  lingual  arteries. 

The  Meningeal  hrayich  ascends  between  the  carotid 
artery  and  jugular  vein,  and  supplies  these  vessels,  the 
pneumogastric  nerve,  the  Eustachian  tube,  the  rectus 
capitis  anticus  and  longus  colli  muscles.  It  then  passes 
through  the  foramen  lacerum  posterius  to  ramify  on  the 
dura  mater,  having  previously  sent  a  small  branch  into 
the  cranium  through  the  cartilaginous  substance  that 
fills  the  foramen  lacerum  anterius. 

This  artery  is  not  very  liable  to  accident,  on  account 
of  its  deep  situation.  Scarpa,  however,  relates  a  case 
in  which  it  was  ruptured. 

The  Transversalis  Faciei  Artery  usually  arises  from 
the  outer  part  of  the  external  carotid  a  little  before  its 
termination.  At  its  origin  it  is  imbedded  in  the  parotid 
gland,  through  which  it  proceeds  outwards  towards  the 
integuments,  then  turns  round  the  ramus  of  the  lower 
jaw,  and  ascends  slightly  on  the  cutaneous  surface  of 
the  masseter  muscle.  In  this  situation  it  lies  above  the 
duct  of  the  parotid  gland,  concealed  by  the  socia  paro- 
tidis  and  surrounded  by  the  filaments  of  the  facial  nerve. 
This  artery  sends  a  twig  to  the  masseter  muscle,  which 
anastomoses  with  a  branch  of  the  internal  maxillary; 


BRANCHES  OP  THE  TEMPORAL.  113 

farther  on,  it  sends  several  twigs  to  the  parotid  gland 
and  its  duct,  and  after  supplying  the  zygomatic  muscles, 
the  orbicularis  palpebrarum  and  the  integuments,  it  ter- 
minates by  anastomosing  with  the  infra-orbital,  buccal, 
and  facial  arteries. 

The  Superficial  Temporal  Artery  arises  immediately 
behind  the  neck  of  the  inferior  maxillary  bone,  and  as- 
cends through  the  parotid  gland  in  front  of  the  external 
auditory  canal.  It  next  passes  between  the  attrahens 
auris  muscle  and  the  horizontal  ramus  of  the  zygoma, 
and  ascends  into  the  temporal  region,  accompanied  by 
the  superficial  temporal  tw^ig  of  the  inferior  maxillary 
division  of  the  fifth  nerve  :  here  it  lies  on  the  temporal 
aponeurosis,  and  is  covered  by  a  fascia  of  considerable 
strength,  which  is  continuous  with  the  cervical  aponeu- 
rosis covering  the  parotid  gland.  In  the  middle  of  the 
temporal  region  the  artery  terminates  by  dividing  into 
two  branches. 

The  temporal  artery  gives  off  the  following  branches : 

Glandular.  Anterior  Auricular. 

Masseteric.  Middle  Deep  Temporal. 

Articular.  Anterior  Temporal. 

Posterior  TemjDoral. 

The  Glandular  branches  are  small  twigs  which  come 
off  from  the  artery,  and  are  distributed  to  the  structure 
of  the  parotid  gland. 

The  Masseteric  branch  is  a  small  twig  which  passes 
forwards  from  the  artery  to  supply  the  masseter  muscle : 
there  may  be  two  or  even  more  of  these  twigs. 

The  Articular  branch  also  passes  forwards  and  supplies 
the  structures  entering  into  the  formation  of  the  tem- 
poro-maxillarj^  articulation :  this  branch  is  also  called 
the  capsular  artery. 

10* 


114  INTERNAL    MAXILLARY   ARTERY. 

The  Anterior  auricular  branch  passes  backwards  to 
supi^ly  the  pavilion  and  auditory  canal :  it  anastomoses 
with  branches  of  the  posterior  auris. 

The  Middle  deep  temporal  artery  arises  immediately 
above  the  zygoma,  pierces  the  temporal  aponeurosis^  and 
divides  into  several  branches  which  ramify  in  the  tem- 
poral muscle,  and  communicate  with  the  other  temporal 
arteries. 

The  Anterior  temporal  branch  ascends  tortuously  to- 
wards the  forehead,  supplies  the  integuments,  orbicularis 
palpebrarum,  and  muscles  of  the  forehead,  and  anasto- 
moses with  the  corresponding  artery  of  the  opposite 
side,  and  with  the  frontal  and  supra-orbital  arteries. 
This  is  the  branch  selected  for  arteriotomy. 

The  Posterior  temporal  branch  ramifies  on  the  side  of 
the  head,  and  anastomoses  with  the  arter3^  of  the  opposite 
side,  and  with  the  occipital  and  posterior  auris  arteries. 

The  temporal  artery  is  not  subject  to  much  variety : 
it  may,  however,  arise  nearer  the  angle  of  the  inferior 
maxillary  bone  than  we  have  above  described,  in  which 
case  it  usually  gives  off  the  transversalis  faciei.  This 
vessel  should  never  be  opened  near  the  zygoma,  as  un- 
manageable hemorrhage  or  inflammation  and  abscesses 
may  be  the  consequence.  Mr.  Harrison  mentions  a  case 
in  which  this  practice  was  followed  by  a  varicose  aneu- 
rism. The  anterior  branch  should  be  selected  for  arte- 
riotomy; and  should  a  small  aneurism  be  the  result,  as 
occasionally  happens,  it  maybe  cured  by  compression,  or 
by  making  an  incision  through  the  tumor,  turning  out 
the  coagulum,  and  dressing  it  from  the  bottom.  Mr. 
Liston  advises  to  divide  the  artery  at  each  side  of  the 
tumor,  and  tie  the  bleeding  extremities. 

The  Internal  Maxillary  Artery  may  be  exposed  in 
the  following  manner:  having  removed  the  brain  and 
uncovered  the  masseter  muscle,  we  may  carry  a  yery 


INTERNAL    MAXILLARY   ARTERY.  115 

small  and  pointed  saw  upwards  behind  the  posterior  ex- 
tremity of  the  zygoma,  and  divide  it  from  within  out- 
wards as  near  its  roots  as  possible.  We  next  remove  the 
roof  and  contents  of  the  orbit  in  the  usual  manner,  and 
sink  the  point  of  the  saw  into  the  anterior  extremity  of 

Fig.  U.— Internal  Maxillary  Artery. 


1,  Right  Common  Carotid.  2,  Internal  Caroti^i.  3,  External  Carotid.  4,  Superior  Thyroid.  5, 
Lingual.  6,  Facial.  7,  Occipital.  8,  Posterior  Auricular.  9,  Parotid  Branch.  10,  Temporal  Artery. 
11,  Internal  Maxillary.  12,  Tympanic.  13,  The  Great  and  Small  Meningeal  Arteries  tVom  a  Common 
Branch.  14,  Inferior  Dental  Artery.  15,  Muscular  Brauelies.  IG,  Superior  Maxillary  Artery  giving 
oflf  the  Posterior  Dental  Arteries.     17,  18,  Infra-orbital  Artery. 

the  spheno-maxillary  fissure,  and  from  this  point  make 
two  incisions ;  one  upwards  and  outwards  through  the 
outer  wall  of  the  orbit  to  terminate  at  the  external  an- 
gular process  of  the  frontal  bone :  the  other  downwards 
and  inwards  through  the  floor  of  the  orbit  to  terminate 


116  INTERNAL    MAXILLARY   ARTERY. 

on  the  outside  of  the  supra-orbital  foramen.  These  two 
incisions  will  include  the  greater  part  of  the  malar  bone, 
and  the  zygoma  will  fall  down,  carrying  with  it  the  mas- 
seter  muscle.  Our  next  object  is  to  detach  the  temporal 
muscle  and  vessels  from  the  temporal  fossa,  and  allow 
them  to  hang  down  from  the  coronoid  process  of  the 
inferior  maxillary  bone.  We  then  introduce  a  knife 
into  the  temporo-maxillary  articulation  above  the  fibro- 
cartilage,  and  divide  the  portion  of  the  capsular  liga- 
ment which  connects  the  latter  to  the  circumference  of 
the  glenoid  cavity.  Lastly,  we  make  two  incisions, 
meeting  internally  at  an  angle,  so  as  to  include  the 
greater  part  of  the  squamous  plate  of  the  temporal  bone, 
and  the  great  wing  of  the  sphenoid  bone;  one  of  these 
incisions  may  commence  immediately  in  front  of  the  ear, 
and  be  continued  vertically  down  through  the  side  and 
base  of  the  skull  till  it  terminates  immediately  behind 
and  external  to  the  spinous  process  of  the  sphenoid  bone ; 
the  second  may  be  made  with  a  small  saw,  and  as  the 
malar  bone  is  already  removed,  the  incision  may  be 
readily  made  to  connect  the  inferior  angle  of  the  sphe- 
noidal fissure  with  the  internal  extremity  of  the  pre- 
ceding incision :  on  the  inside  of  the  latter,  the  foramen 
ovale  and  foramen  rotundum  should  lie  unopened.  A 
slight  stroke  of  the  hammer  against  the  bone  between 
these  two  incisions  will  detach  it,  and  give  a  full  view 
into  the  zygomatic  fossa :  the  branches  of  the  artery  may 
then  be  dissected.  The  vidian  and  posterior  palatine 
canals  can  be  readily  broken  into,  if  a  vertical  section  of 
the  skull  be  previously  made  through  the  adjacent  nos- 
tril. The  artery  may  be  very  readily  exposed  by  another 
method :  after  the  transversalis  faciei  artery,  together 
with  the  masseter  muscle  and  its  superficial  relations, 
have  been  examined  and  removed,  a  horizontal  section 
may  be  made  through  the  ramus  of  the  inferior  maxilla 


INTERNAL   MAXILLARY   ARTERY.  117 

immediately  above  its  angle  with  a  fine  metacarpal  saw; 
care  being  taken  that  none  of  the  soft  parts  under  cover 
of  the  bone  shall  be  injured :  another  horizontal  section 
may  now  be  made  through  the  neck  of  the  jaw,  imme- 
diately below  the  condyle,  and  the  coronoid  process  re- 
moved from  its  connection  with  the  temporal  muscle. 
The  piece  of  bone  included  between  the  two  incisions 
may  also  be  removed,  and  afterwards  can  be  replaced  at 
pleasure.  The  zygomatic  arch  should  be  next  taken 
away,  and  this  may  be  done  by  two  incisions, — one  made 
posteriorly  through  this  process  of  bone,  close  to  its 
origin, — the  other  anteriorly,  close  to  the  external  part 
of  the  orbit  through  the  zygomatic  process  of  the  malar 
bone. 

The  internal  maxillary  artery  is  larger  than  the  tem- 
poral, and  together  with  it  is  contained  for  a  very  short 
distance  within  the  parotid  gland.  It  may  be  divided 
into  four  stages :  the  first  stage  extends  from  its  origin 
to  the  inter-pterygoid  space;  its  second  corresponds  to 
this  space;  its  third  extends  from  this  space  to  the  upper 
part  of  the  ptery go-maxillary  fossa,  and  thQ  fourth  is  the 
termination  of  the  artery  in  this  fossa.  In  its  first  stage 
it  runs  horizontally  forwards  and  lies  on  the  inside  of 
the  lower  portion  of  the  neck  of  the  inferior  maxillary 
bone,  which  it  separates  from  the  internal  lateral  liga- 
ment of  the  temporo-maxillary  articulation :  the  bone  is 
frequently  grooved  in  this  situation  for  the  reception  of 
the  artery.  In  its  second  stage  we  find  it  passing  for- 
wards and  inwards,  forming  a  curvature  the  concavity 
of  which  looks  upwards  and  embraces  the  external 
pterygoid  muscle:  in  this  part  of  its  course  it  lies  in 
a  triangular  space,  bounded  by  the  external  pterygoid 
muscle  above,  the  internal  pter3^goid  beneath,  and  the 
ramus  of  the  lower  jaw  externally.  In  the  same  trian- 
gular space  we  observe  the  gustatory  and  inferior  dental 


118  BRANCHES   OF    THE   INTERNAL    MAXILLARY. 

nerves,  descending  to  their  destination,  but,  as  the  artery 
lies  close  to  the  neck  of  the  inferior  maxilla,  it  is  situated 
external  to  these  nerves.  In  the  third  stage  we  find  the 
artery  running  upwards  and  inwards  towards  the  root 
of  the  pterygoid  process,  after  passing  between  the  outer 
surface  of  the  external  pterygoid  muscle,  and  the  fibres 
of  the  temporal  muscle.  In  this  situation  the  artery  is 
related  to  the  buccal  nerve;  at  first  the  artery  is  poste- 
rior to  the  trunk  of  the  nerve,  and  afterwards  lies  upon 
a  plane  external  to  it.  Finally  it  sinks  between  the  two 
origins  of  the  external  pterygoid  muscle,  and  terminates 
in  the  pterygo-maxillary  fossa  lying  to  the  outside  of 
Meckel's  ganglion,  and  the  spheno-palatine  foramen : 
this  constitutes  its  fourth  stage.  In  some  (not  very  rare) 
cases  the  artery  passes  to  its  destination,  not  through 
the  inter-pterygoid  space  as  above  described,  but  between 
the  external  pter^^goid  muscle  and  the  base  of  the  skull. 
We  shall  now  examine  its  branches  in  the  order  in 
which  they  arise. 

The  internal  maxillary  artery  gives  ofi"  the  following 
branches : — 

Middle  Meningeal.  Buccal. 

Tympanic.  Anterior  Deep  Temporal. 

Inferior  Dental.  Posterior  Superior  Dental. 

Meningea  Parva.  Infra-Orbital. 

Posterior  Deep  Temporal.   Vidian. 

Masseteric.  Superior  Palatine. 

Pterygoid.  Spheno-Palatine. 

The  Middle  meningeal  artery  is  the  largest  branch  of 
the  internal  maxillary.  It  arises  on  the  inside  of  the 
neck  of  the  lower  jaw,  and  ascends  obliquely  inwards  to 
the  base  of  the  skull,  behind  the  external  pterygoid  mus- 
cle, which  consequently  separates  it  from  the  continued 
trunk  of  the  internal  maxillary  artery.     In  this  part  of 


BRANCHES    OF    THE    INTERNAL    MAXILLARY.  119 

its  course  it  usually  passes  between  the  roots  of  the  tem- 
poro-auricular  nerve,  lies  posterior  to  the  otic  ganglion, 
and  then  enters  the  spinous  foramen  in  the  base  of  the 
skull,  after  passing  between  the  origin  of  the  circumflexus 
palati  muscle  in  front,  and  the  internal  lateral  ligament 
of  the  lower  jaw  posteriorly.  In  this  part  of  its  course, 
it  supplies  the  pterygoid  muscles,  the  muscles  of  the 
pharynx,  and  the  temporal  and  sphenoid  bones. 

Having  passed  within  the  skull,  the  middle  meningeal 
artery  ascends  beneath  the  dura  mater  into  the  middle 
fossa  of  the  cranium,  and  terminates  by  dividing  into  an 
anterior  and  posterior  terminating  branch. 

Before  its  division  it  sends  a  branch  through  the 
spheno-frontal  fissure  to  terminate  in  the  lachrymal 
gland;  another  through  the  hiatus  Fallopii,  which  sup- 
plies the  facial  nerve  and  anastomoses  with  the  stylo- 
mastoid artery;  and  a  third  through  the  canal  for  the 
internal  muscle  of  the  malleus,  to  be  distributed  on  the 
lining  membrane  of  the  tympanum. 

The  anterior  terminating  branch,  much  larger  than  the 
posterior,  ascends  through  the  groove  in  the  great  wing 
of  the  sphenoid  bone,  and  the  anterior  inferior  angle  of 
the  parietal  bone,  the  groove  in  the  latter  being  fre- 
quently converted  into  a  complete  osseous  canal.  The 
artery  is  here  situated  about  one  inch  behind  the  exter- 
nal angular  process  of  the  frontal  bone,  and  divides  into 
numerous  branches  that  radiate  in  all  directions  on  the 
internal  surface  of  the  parietal  and  adjacent  bones : 
these  branches  are  principally  lost  on  the  dura  mater;  a 
few  of  them  penetrate  the  sutures  and  supply  the  diploe 
of  the  bones.  This  artery  has  been  frequently  torn  in 
injuries  of  the  head,  and  has  given  rise  to  considerable 
hemorrhage  between  the  dura  mater  and  the  bone.  It 
may  also  be  wounded  in  the  operation  of  trephining : 
the  hemorrhage  may,  however,  be  easily  controlled  by 


120  BRANCHES    OF    THE    INTERNAL    MAXILLARY. 

the  application  of  a  dossil  of  lint.  The  posierior  termi- 
nating branch  curves  backwards  as  it  ascends  on  the  in- 
ternal surface  of  the  squamous  plate  of  the  temporal 
bone.  Its  branches  communicate  with  each  other,  and 
terminate  in  the  dura  mater  and  bone. 

The  Tympanic  artery  is^a  very  small  branch ;  it  some- 
times arises  from  that  branch  of  the  temporal  which  goes 
to  supply  the  temporo-maxillary  articulation;  it  passes 
through  the  Glasserian  fissure  into  the  tympanum,  and 
ramifies  upon  the  membrane  lining  the  interior  of  this 
cavity,  and  in  the  muscles  contained  Avithin  it. 

The  Inferior  dental  artery  arises  from  the  inferior  sur- 
face of  the  internal  maxillary,  nearly  opposite  the  origin 
of  the  middle  meningeal,  and  runs  obliquely  downwards 
and  forwards,  between  the  internal  lateral  ligament,  and 
the  ramus  of  the  lower  jaw.  In  this  course  it  sends 
numerous  branches  to  the  pterygoid  muscles,  and  to  the 
gustatory  and  inferior  maxillary  nerves.  Lower  down 
it  gives  off  a  mylo-hyoidean  branch  which  descends  in  the 
groove  leading  from  the  dental  foramen,  accompanied  by 
the  mylo-hyoidean  branch  of  the  inferior  dental  nerve, 
and  supplies  the  mylo-hyoid  muscle  and  mucous  mem- 
brane of  the  mouth.  Immediately  after  giving  off  this 
last  branch,  the  inferior  dental  artery  enters  the  dental 
foramen,  in  company  with  the  dental  nerve,  which  is 
situated  in  front  of  it.  It  descends  beneath  the  alveoli, 
till  it  arrives  at  the  first  molar  tooth,  where  it  divides 
into  two  branches;  one  of  which  is  continued  to  the 
symphisis  menti,  supplying  the  alveoli  of  the  canine  and 
incisor  teeth;  the  other  escapes  by  the  mental  foramen, 
together  w^ith  the  mental  branch  of  the  inferior  dental 
nerve,  to  supply  the  integuments,  and  triangularis  and 
depressor  labii  inferioris  muscles;  it  anastomoses  with 
the  adjacent  branches  of  the  facial  artery.  In  its  course 
through  the  inferior  maxillary  bone  it  sends  branches 


BRANCHES    OP    THE    INTERNAL    MAXILLARY.  121 

into  the  alveoli,  each  of  which  penetrates  the  bottom 
of  the  tooth  to  be  distributed  on  the  membrane  lining 
its  cavity. 

The  Meningea  parva  artery  is  not  a  constant  branch; 
when  it  exists  it  arises  from  the  internal  maxillary, 
close  to  the  origin  of  the  inferior  dental.  Some  of  its 
branches  are  distributed  to  the  soft  palate  and  the  nasal 
fosssa:  a  principal  branch  of  the  artery  passes  upwards 
through  the  foramen  ovale  and  supplies  the  inferior 
maxillary  nerve,  Casserian  ganglion,  and  dura  mater. 

The  Posterior  deep  temporal  artery  arises  from  the 
internal  maxillary,  while  the  latter  is  passing  between 
the  two  pterygoid  muscles  -,  it  ascends  between  the  tem- 
poral and  external  pterygoid  muscles,  and  then  between 
the  temporal  muscle  and  the  side  of  the  cranium :  to  all 
these  parts  it  sends  numerous  minute  branches  which 
ultimately  terminate  in  anastomosing  with  the  deep  tem- 
poral branch  from  the  superficial  temporal  artery. 

The  Masseteric  artery  also  arises  in  the  triangular 
space  between  the  two  pterygoid  muscles  and  ramus  of 
the  lower  jaw.  It  passes  outwards  through  the  sigmoid 
notch  that  separates  the  coronoid  process  from  the 
cond^'le  of  the  inferior  maxilla,  and  then  descends  on 
the  outer  side  of  its  ramus,  supplies  the  masseter  muscle, 
and  anastomoses  with  the  transversalis  faciei  artery. 

The  Pterygoid  branches  are  numerous :  some  of  them 
are  distributed  to  the  internal  pterygoid  muscle,  and  a 
still  greater  number  to  the  external  pterygoid. 

The  Buccal  artery  runs  tortuously,  downwards,  for- 
wards, and  outwards,  between  the  two  pterygoid  muscles, 
and  in  company  with  the  buccal  nerve.  Having  arrived 
at  the  anterior  margin  of  the  ramus  of  the  inferior 
maxillary  bone,  it  penetrates  the  cheek  and  divides  into 
a  number  of  branches,  which  are  distributed  to  the 
platysma  myoides,  buccinator  and'  zygomatic  muscles, 

11 


122  BRANCHES   OF   THE   INTERNAL   MAXILLARY. 

and  also  to  the  integuments  of  the  cheek,  and  to  its 
mucous  membrane  and  follicles.  It  anastomoses  with 
the  facial,  infra-orbital,  and  transversalis  faciei  arteries: 
in  some  cases  it  is  deficient,  and  in  others  it  arises  from 
some  other  branch  of  the  internal  maxillary. 

The  Ayiterior  deep  temporal  artery  usually  comes  off 
from  the  internal  maxillary,  as  this  artery  lies  between 
the  external  pterygoid  and  temporal  muscles  ]  it  ascends 
in  the  anterior  part  of  the  temporal  fossa  to  supply  the 
temporal  muscle,  and  to  anastomose  with  the  other  tem- 
poral arteries.  Some  of  its  branches  penetrate  the 
malar  bone  to  reach  the  lachrymal  gland  and  communi- 
cate with  the  lachrymal  artery. 

The  Posterior  superior  dental  artery  descends  tortuously 
on  the  back  of  the  antrum.  Some  of  its  branches  pierce 
the  superior  maxillary  bone,  and  supply  the  molar  teeth 
and  mucous  membrane  of  the  antrum,  while  others  are 
distributed  to  the  teeth,  gums,  and  buccinator  muscle: 
they  anastomose  with  the  labial,  buccal,  and  infra-orbital 
arteries. 

The  Infra-orbital  artery  passes  through  a  canal  of  the 
same  name  in  the  floor  beneath  the  orbit,  in  company 
with  the  infra-orbital  nerve  beneath  which  it  lies.  In 
this  course  it  sends  some  small  branches  to  the  inferior 
rectus  and  inferior  oblique  muscles  of  the  eye.  Having 
arrived  at  the  anterior  part  of  this  canal,  it  gives  off 
the  anterior  superior  dental  branch,  which  descends 
through  the  anterior  wall  of  the  antrum,  to  supply  its 
mucous  membrane,  and  the  canine  and  incisor  teeth. 
After  giving  off  this  branch,  it  leaves  the  infra-orbital 
canal,  and  is  found  on  the  face  beneath  the  outer  head 
of  the  levator  labii  superioris  alseque  nasi,  and  lying  on 
the  levator  anguli  oris.  In  this  situation  it  supplies  the 
adjacent  muscles,  and  anastomoses  with  the  facial, 
dental,  buccal,  and  nasal  arteries. 


BRANCHES   OF   THE   INTERNAL   MAXILLARY.  123 

The  Vidian  artery,  extremely  small,  passes  backwards 
through  the  Yidian  canal  above  the  root  of  the  internal 
pterygoid  plate,  and  enters  the  aqueduct  of  Fallopius 
through  the  hiatus  Fallopii.  It  supplies  the  facial  nerve, 
Eustachian  tube,  and  pharynx,  and  anastomoses  with 
the  pharyngea  ascendens,  and  with  the  stylo-mastoid 
branch  of  the  occipital  artery.  This  vessel  is  some- 
times given  off  by  the  trunk  of  the  middle  meningeal. 

The  Superior  palatine  artery  descends  obliquely  for- 
wards through  the  posterior  palatine  canal.  In  this 
situation  it  sends  two  or  three  small  branches  through 
the  accessory  palatine  canals  to  the  velum  palati.  The 
continued  trunk  after  leaving  the  posterior  palatine 
canal  advances  on  the  roof  of  the  mouth,  and  is  dis- 
tributed to  its  lining  membrane,  and  to  the  gums  and 
superior  maxillary  bone.  At  the  foramen  incisivum  it 
communicates  with  the  spheno-iDalatine  arteries,  which 
descend  from  the  nose  through  the  anterior  palatine 
canals. 

The  Spheno-palatine  artery  may  be  considered  as  the 
terminating  branch  of  the  internal  maxillary.  It  passes 
through  the  spheno-palatine  foramen  into  the  cavity  of 
the  nose,  where  it  gives  off  a  pterygo-palatine  branch, 
and  then  divides  into  its  terminating  branches.  The 
pterygo-palatine  branch  sometimes  comes  off  directly 
from  the  internal  maxillary;  it  passes  backwards  from 
its  origin  through  the  pterygo-palatine  canal  and  sup- 
plies the  pharynx  and  Eustachian  tube.  The  termi- 
nating branches  of  the  spheno-palatine  are  two  or  more 
in  number:  one  of  them  descends  on  the  septum 
nasi,  with  the  spheno-palatine  nerve,  and  communicates 
with  the  superior  palatine  artery :  the  others  are  dis- 
tributed in  the  superior  and  middle  meatus,  in  the 
antrum,  and  in  the  posterior  ethmoidal  cells:  they  com- 
municate with  the  ethmoidal  arteries,  and  form  between 


124 


INTERNAL    MAXILLARY   ARTERY. 


Fig.  15.- 


-Dissection  of  the  Internal  Maxillary,  Middle  Meningeal,  and  part  of  the 
course  of  the  Facial,  Arteries. 


A,  Kxternal  Carotid  Artery.  B,  B,  Internal  Maxillary  Artery.  C,  C,  Superficial  Temporal 
Artery.  D,  Facial  Artery.  I,  I,  I,  Vertical  section  through  Frontal,  Parietal,  and  Occipitul  Bones. 
K,  Middle  Meningeal  Artery.  P,  Mental  branch  of  Inferior  Dental  Artery,  a.  Branch  to  the  Mas- 
seter  Muscle,  b.  Branch  toParotid  Gland,  c,  Posterior  Auris  Artery,  d,  A  twig  from  the  Internal 
Maxillary  to  Internal  Pterygoid  Muscle,  e,  Inferior  Dental  Artery  proceeding  to  the  Dental  Canal 
of  the  lower  jaw.  f,  Buccal  Artery,  g.  Posterior  Superior  Dental  Artery,  h,  Anterior  deep  Tempo- 
ral Artery,  i,  Posterior  deep  Temporal  Artery.  1,  1,  1,  Distribution  of  the  Middle  Meningeal  Artery 
after  having  entered  the  Cranium  through  the  Spinous  Foramen  of  the  Sphenoid  Bone,  m,  Artery 
of  the  Filtrum.  n,  Branch  of  Temporal  Artery,  o,  Facial  Artery  ascending  to  upper  lip  and  nose. 
2,  2,  2,  Continuation  of  Middle  Meningeal  ramifying  beneath  the  Dura  Mater.  3,  Temporal  Fossa. 
4,  4,  Orbicularis  Palpebrarum  Muscle.  5,  5,  Zjgomatic  Arch  cut  through.  6,  External  Pterygoid 
Muscle  cut  across.  7,  Internal  Pterygoid  Muscle.  8,  Ramus  of  the  lower  jaw  cut.  9,  Masseter 
Muscle  cut.  10,  Buccinator.  11,  Parotid  Duct  cut  across.  12,  Levator  Labii  Superioris  Alaeque  Nasi. 
13,  Portion  of  Levator  of  the  upper  Lip.  14,  Part  of  Zygomaticus  Minor.  15,  Part  of  Zygomaticus 
Major.  16, 16,  Depressor  Labii  Inferioris  cut  across.  17,  Orbicularis  Oris  Muscle.  18,  18,  Quadratus 
Meuti  Muscle  divided. 


INTERNAL   CAROTID   ARTERY.  125 

the  mucous  membrane  and  periosteum,  a  vascular  net- 
work, deeply  tinging  the  former  membrane. 

Sir  B.  Brodie  tied  the  common  carotid  in  conse- 
quence of  hemorrhage  from  the  posterior  superior  dental 
branch  of  the  internal  maxillary  artery  after  extrac- 
tion of  the  second  molar  tooth  of  the  upper  jaw ;  the 
hemorrhage,  however,  proved  fatal.*  In  ordinary  cases 
of  this  kind  we  may  plug  up  the  socket,  or  apply  the 
actual  cautery,  or,  if  practicable,  the  tooth  should  be 
replaced. 

THE  INTERNAL  CAROTID  ARTERY. 

This  artery  may  be  exposed  in  the  following  manner: 
The  brain  should  'first  be  removed  in  the  usual  way, 
leaving  uninjured,  however,  the  cerebellum,  medulla 
oblongata,  and  pons  Varolii :  the  tentorium  should  now 
be  removed,  and  the  cerebellum  pushed  gently  forward, 
or  a  small  portion  of  its  posterior  part  removed,  so  as 
to  make  room  for  the  saw.  A  vertical  section  of  the 
cranium  should  be  next  made  through  the  posterior  part 
of  the  occipital  foramen  and  through  the  cervical  verte- 
brae, behind  their  articular  processes.  This  section  will 
enable  the  student  to  study  the  medulla  oblongata,  ver- 
tebral arteries  and  their  branches,  and  the  eighth,  ninth, 
and  sub-occipital  nerves.  After  these  parts  have  been 
examined,  the  cerebellum  and  spinal  marrow  may  be 
removed,  and  the  ligaments  divided  which  connect  the 
occipital  bone  to  the  first  and  second  vertebra).  The 
vertebrae  may  now  be  separated  from  the  occipital  bone, 
the  recti  capitis  antici  muscles  having  been  previously 
detached  from  the  front  of  the  spine,  but  allowed  to  re- 
main in  connection  with  the  occipital  bone.  Lastly,  the 
lower  part  of  the  neck  may  be  cut  across,  and  the  di- 
gastric and  styloid  muscles,  &c.  neatly  dissected.     The 

*  Med.  Chirurg.  Trans.,  vol.  viii. 
11* 


126 


INTERNAL  CAROTID  ARTERY. 


portion  of  the  internal  carotid  contained  in  the  osseous 
canal  must  be  carefully  followed  with  a  chisel,  and  its 
exact  relation  to  the  cochlea,  tympanum,  and  Eustachian 

Fig.  16.~Arteries  of  the  Interior  of  the  Cranium. 


1,  Internal  Carotid  Arteries.  2,  Ophthalmic  Artery.  3,  Posterior  communicating  Arteries.  4, 
Anterior  Cerebral  Arteries.  5,  Anterior  communicating  Artery.  6,  Middle  Cerebral  Arteries.  7, 
Lachrymal.  8,  Short  Ciliary  Arteries  piercing  the  back  part  of  the  Eyeball.  9,  Central  Retinal 
piercing  the  Optic  Nerve  to  reach  the  interior  of  the  Eyeball.  10,  Muscular  Artery.  11,  Frontal 
and  Nasal  Artery.  12,  Vertebral  Arteries.  13,  Posterior  Meningeal  Artery.  14,  Posterior  Spinal 
Artery.  15,  Anterior  Spinal  Arteries  conjoining  in  a  single  one.  16,  Inferior  Cerebellar  Arteries. 
17,  Basilar  Artery  formed  by  the  union  of  the  Vertebrals.  18,  Internal  Auditory.  19,  Superior  Cere- 
bellar.   20,  Posterior  Cerebral  Arteries. 


tube  may  be  seen  if  a  metallic  cast  of  the  ear  be  pre- 
viously taken,  and  the  bone  softened  in  dilute  acid. 

The  Internal  Carotid  is  much  larger  than  the  ex- 
ternal in  the  young  subject,  but  nearly  of  equal  size  in 
the  adult :  it  arises  ojjposite  the  superior  margin  of  the 


INTERNAL   CAROTID  ARTERY.  127 

thyroid  cartilage,  and  its  long  and  tortuous  course  may 
be  divided  into  four  stages:  the  first  extends  from  its 
origin  to  the  petrous  portion  of  the  temporal  bone ;  the 
second  through  the  carotid  canal  in  this  portion  of  the 
bone;  the  third  passes  through  the  cavernous  sinus; 
and  the  fourth  is  in  immediate  relation  with  the  base  of 
the  brain. 

In  its  first  stage  it  constantly  forms  a  curvature,  the 
convexity  of  which  looks  outwards,  and  lies,  for  a  short 
distance,  to  the  outside  of  the  external  carotid  artery. 
In  the  remainder  of  its  ascent  to  the  base  of  the  skull 
it  usually  forms  a  number  of  other  tortuosities  seldom 
alike  in  any  two  subjects.  Its  posterior  surface  corre- 
sponds to  the  spine,  rectus  capitis  anticus  major  muscle, 
and  to  the  superior  cervical  ganglion,  from  which  it  is 
separated  by  the  superior  laryngeal  and  usually  by  the 
pharyngeal  branch  of  the  pneumogastric  nerve.  Near 
the  base  of  the  skull  the  internal  jugular  vein  lies  poste- 
rior and  a  little  external  to  it,  but  separated  from  it  by 
the  hypo-glossal,  glosso-pharyngeal,  and  pneumogastric 
nerves  immediately  after  their  exit  from  the  interior 
of  the  cranium.  Shortly  after  its  first  curvature,  its 
anterior  surface  is  covered  inferiorly  by  the  external 
carotid,  from  which  it  is  separated  a  little  higher  up 
by  the  stylo-glossus  and  stylo-pharyngeus  muscles,  the 
styloid  process,  or  by  the  stylo-hyoid  ligament,  a  por- 
tion of  the  parotid  gland,  the  glosso-pharyngeal  nerve, 
and  occasionally  the  pharyngeal  branch  of  the  pneumo- 
gastric nerve.  Immediately  before  it  pierces  the  base 
of  the  cranium,  its  anterior  surface  is  related  to  the 
Eustachian  tube  and  origin  of  the  levator  palati  muscle. 
Its  external  surface  corresponds  to  the  glosso-pharyngeal 
nerve,  to  a  portion  of  the  styloid  process,  to  the  origin 
of  the  stylo-pharyngeus  muscle,  to  an  aponeurosis  sepa- 
rating it  from  the  parotid  gland,  and  to  the  internal 


128  INTERNAL    CAROTID    ARTERY. 

jugular  vein.  Its  internal  surface  corresponds  to  the 
pharynx  and  the  pharyngea  ascendens  artery,  and 
higher  up  to  the  tonsil.  In  this  locality  the  vessel  is 
lodged  in  an  angular  space  formed  by  the  j)terygoid 
muscles  on  the  outside,  and  the  superior  constrictor  of 
the  pharynx  on  the  inside.  Near  the  termination  of  its 
first  stage  the  superior  cervical  ganglion  of  the  sympa- 
thetic nerve,  which  lies  behind  it,  gives  off  a  consider- 
able branch  which  appears  to  be  a  prolongation  of  the 
upper  extremity  of  the  ganglion;  this  branch  soon 
divides  into  two  others,  one  at  the  inner  and  the  other 
at  the  outer  side  of  the  vessel;  they  communicate  in 
this  situation  with  minute  filaments  from  the  glosso- 
pharyngeal nerve,  and  together  with  the  artery  they 
enter  the  carotid  canal  and  there  form  the  carotid  plexus 
of  nerves.  The  tonsil  lies  anterior  and  internal  to  the 
artery.  The  artery  gives  off  no  regular  branches  in  the 
first  stage. 

In  its  second  stage,  we  trace  it  forwards  and  inwards 
through  the  carotid  canal,  running  in  a  curved  direc- 
tion, surrounded  by  the  carotid  plexus  and  also  by  a 
few  small  veins  which  terminate  in  the  cavernous  sinus. 
In  this  canal  it  is  situated  anterior  and  internal  to  the 
cavity  of  the  tympanum,  from  which  it  is  separated 
only  by  a  thin  partition  of  bone:  it  lies  inferior  to  the 
cochlea,  and,  at  the  commencement  of  this  stage,  in- 
ferior also  to  the  Eustachian  tube;  superior  to  which, 
however,  it  gradually  passes  as  it  enters  upon  its  third 
stage.  Having  emerged  from  the  carotid  canal,  it  passes 
obliquely  over  the  cartilaginous  substance  which  fills  the 
foramen  lacerum  anterius  or  spheno-temporal  fissure; 
it  then  enters  the  cranium,  and  here  its  second  stage 
terminates. 

In  its  third  stage  the  artery  advances  through  the 
cavernous  sinus,  making  two  curvatures  in  the  form  of  a 


INTERNAL   CAROTID   ARTERY.  129 

Roman  o^,  being  first  convex  superiorly,  and  more  in 
front  convex  inferiorly :  as  it  passes  through  the  sinus, 
it  is  crossed  from  behind  forwards  by  the  sixth  nerve, 
which  is  closely  applied  to  its  external  surface:  the 
carotid  plexus  of  nerves  surrounds  the  artery  within 
the  sinus,  and  a  branch  or  two  of  the  sympathetic  nerve 
may  be  observed  ascending  on  its  outside  and  joining 
the  sixth  nerve,  as  the  latter  is  passing  the  carotid 
artery.  More  externally,  and  in  the  outer  wall  of  the 
cavernous  sinus,  are  situated  the  third,  fourth,  and 
ophthalmic  branch  of  the  fifth  nerve :  these  nerves  are 
placed  in  their  numerical  order,  from  above  down- 
wards, and  from  within  outwards.  The  lining  mem- 
brane of  the  sinus  is  reflected  on  the  artery  and  on  the 
nerves  in  immediate  connection  with  it,  thus  forming  a 
sheath  which  separates  them  from  the  blood  of  the  sinus. 

On  emerging  from  the  cavernous  sinus,  the  artery 
pierces  the  dura  mater  and  enters  its  fourth  stage:  on 
reaching  the  under  portion  of  the  anterior  clinoid  pro- 
cess, it  is  here  lodged  in  a  deep  notch,  and  makes  a  turn 
backwards  and  inwards,  and  terminates  on  the  outside 
of  the  commissure  of  the  optic  nerves,  and  at  the  in- 
ternal extremity  of  the  fissure  of  Sylvius,  by  dividing 
into  the  posterior  communicating  and  the  anterior  and 
middle  arteries  of  the  cerebrum.  The  arachnoid  mem- 
brane gives  a  covering  to  the  artery  after  it  has  entered 
into  its  fourth  stage.  Immediately  after  escaping  from 
the  cavernous  sinus  the  internal  carotid  gives  off  the 
ophthalmic  artery,  and  still  later  the  choroid  and  pos- 
terior communicating  arteries:  it  then  terminates  by 
dividing  into  the  arteries  already  mentioned. 

The  internal  carotid  artery  gives  off  the  following 
branches : — 

Tympanic.  Ophthalmic. 

Yidian.  Choroid. 


130  BRANCHES   OP   THE   INTERNAL   CAROTID. 

Eeceptacular.  Posterior  communicating. 

Meningeal.  Anterior  Cerebral. 

Middle  Cerebral. 

The  Tympanic  branch  is  exceedingly  slender:  it  arises 
from  the  artery  in  its  second  stage,  and,  passing  through 
a  portion  of  the  bone,  is  distributed  to  the  tympanum. 

The  Vidian  branch  is  a  very  minute  twig,  given  oif 
also  in  the  second  stage :  it  anastomoses  with  the  vidian 
artery,  a  branch  of  the  internal  maxillary. 

The  Eeceptacular  branches  are  small  twigs  given  oif 
by  the  artfiry  in  its  third  stage :  they  are  distributed  to 
the  dura  mater,  to  the  walls  of  the  inferior  petrosal 
sinus,  and  to  the  pituitary  body. 

The  Meningeal  branch  is  also  distributed  to  the 
dura  mater  in  the  immediate  vicinity,  and  anastomoses 
with  the  middle  meningeal,  a  branch  of  the  internal 
maxillary. 

The  Ophthalmic  artery  is  given  off  from  the  internal 
carotid  in  its  fourth  stage,  beneath  the  anterior  clinoid 
process :  it  may  be  exposed  by  the  following  dissection : 
— The  brain  should  be  removed  from  the  cranium  in 
the  usual  way;  two  vertical  incisions  should  be  next 
made,  commencing,  one  at  the  external  and  the  other 
at  the  internal  angular  process  of  the  frontal  bone:  if 
these  be  directed  so  as  to  meet  posteriorly  in  the  sphe- 
noidal fissure,  they  will  be  found  to  include  between  them 
almost  the  whole  of  the  roof  of  the  orbit,  which  may  be 
then  readily  detached  with  the  hammer.  The  other  parts 
contained  within  the  cavity  of  the  orbit  maybe  exposed 
by  the  same  dissection.  Immediately  after  its  origin 
the  artery  advances  between  the  second  or  optic,  and 
the  third  nerves,  and  enters  the  optic  foramen,  being 
lodged  in  a  fibrous  sheath  formed  for  it  by  the  dura 
mater.     At  first  it  lies  on  the  outside  of  the  optic  nerve, 


OPHTHALMIC  ARTERY  AND  BRANCHES.       131 

then  ascends  to  get  on  its  superior  surface,  where  it  is 
covered  by  the  levator  palpebrse  and  superior  rectus 
muscles,  and  accomj^anied  by  the  nasal  nerve :  lastly,  it 
runs  horizontally  forwards  between  the  internal  rectus 
and  superior  oblique  muscles,  towards  the  internal 
angular  process  of  the  frontal  bone;  here  it  terminates 
by  dividing  into  the  nasal  and  frontal  arteries,  both  of 
which  escape  from  the  orbit  in  company  with  the  infra- 
trochleator  nerve,  passing  above  the  tendo  oculi  and 
beneath  the  pulley  of  the  superior  oblique  muscle. 
The  ophthalmic  artery  gives  off  the  following  branches : 

Lachrymal.  Muscular. 

Central  artery  of  the  Ethmoidal. 

Eetina  Palpebral. 

Supra-Orbital.  Frontal. 

Ciliary.  Nasal. 

The  Lachrymal  artery  is  the  first  and  one  of  the 
largest  branches  of  the  ophthalmic:  it  arises  at  the 
outer  side  of  the  optic  nerve  and  passes  forwards  and 
outwards  between  the  origin  of  the  superior  rectus 
muscle  and  the  superior  head  of  the  external  rectus: 
it  supplies  both  these  muscles,  and  is  conducted  by  the 
superior  margin  of  the  latter  towards  the  lachrymal 
gland:  in  this  part  of  its  course  it  sends  a  branch 
through  the  malar  bone  into  the  temporal  fossa,  which 
anastomoses  with  the  anterior  deep  temporal  artery. 
More  anteriorly  it  gives  off  a  number  of  branches 
which  pass  above,  and  sometimes  round,  the  lachrymal 
gland  to  penetrate  between  its  lobules,  and  to  supply 
its  interior.  Lastly,  the  terminating  branches  are  lost 
in  the  upper  eyelid,  in  anastomosing  with  the  superior 
palpebral  and  anterior  temporal  arteries. 

The  Central  artery  of  the  Retina  is  extremely  minute; 
it  arises  at  the  outer  side  of  the  optic  nerve,  pierces  its 


132 


BRANCHES  OF  THE  OPHTHALMIC. 


coats,  and  runs  forwards  through  its  centre  to  arrive  at 
the  retina,  on  the  internal  surface  of  which  it  forms  a 
vascular  expansion  which  may  be  traced  as  far  forwards 
as  the  ciliary  processes.  Immediately  on  escaping  from 
the  optic  nerve,  it  gives  off  a  branch,  the  Artery  of  ZinUy 

Fig.  11 ,— Dissection  of  some  of  the  branches  of  the  Ophthalmic  Artery . 


1,  Anastomosis  between  the  Lachrymal  and  Superior  Palpebral  Arteries.  2,  Levator  Palpebra 
Superioris  Muscle.  3,  The  Lachrymal  Gland.  4,  Superior  Oblique  Muscle.  5,  Kxternal  Bectua 
Muscle.  6,  Optic  Nerve,  a,  Last  turn  of  Internal  Carotid  Artery  from  which  is  given  off  the  Oph- 
thalmic Artery,  c.  Lachrymal  Artery,  d,  Trunk  of  Ophthalmic  Artery  after  having  passed  beneath 
the  Levator  PalpebrsB  andSuperior  Rectus  Muscles,  e,  e,  Anterior  and"  Posterior  Ethmoidal  Arteries, 
r.  Tendon  of  Superior  Oblique  Muscle  after  having  passed  through  its  pulley,  g,  Nasal  Artery,  h, 
Small  portion  of  Superior  Rectus  Muscle,    i,  Supra-Orbital  Artery  cut  across. 

which  runs  from  behind  forwards  through  the  centre  of 
the  vitreous  humor,  and  contained  within  a  sheath 
formed  by  the  hyaloid  membrane,  called  the  hyaloid 
canal :  it  sends  numerous  small  branches  to  the  hyaloid 
membrane :  in  front  it  ramifies  on  the  posterior  part  of 
the  capsule  of  the  lens,  and  in  the  foetus  its  branches 


CILIARY   ARTERIES.  133 

have  been  traced  to  the  membrana  papillaris.  This 
artery  occasionally  arises  from  one  of  the  ciliary 
arteries. 

The  Supra-orbital  artery  arises  at  the  upper  surface  of 
the  optic  nerve,  and  accompanies  the  nerve  of  the  same 
name  to  the  notch  in  the  superior  margin  of  the  orbit. 
In  this  course  it  lies  on  the  superior  rectus  and  levator 
palpebra)  muscles,  beneath  the  periosteum,  and  on  the 
inside  of  the  supra-orbital  nerve.  It  supj)lies  the  levator 
palpebrsB  and  superior  rectus  muscles;  and  as  it  passes 
through  the  notch  in  the  superciliary  arch,  it  gives  a 
branch  to  the  diplde  of  the  frontal  bone.  It  then  divides 
into  two  principal  branches,  of  which  the  internal  is  the 
larger  :  these  subdivide  into  many  others,  which  supply 
the  occipito-frontalis  muscle,  and  anastomose  with  the 
angular  artery  inferiorly,  and  with  the  temporal  artery 
Buj)eriorly. 

The  Ciliary  arteries  are  divided  into  three  sets, — the 
short,  the  long,  and  the  anterior, — and  at  their  origins 
correspond  to  the  upper  surface  of  the  optic  nerve.  The 
sliort  ciliary  arteries  (twenty,  thirty,  or  sometimes  even 
forty  in  number)  advance  tortuously  through  the  fatty 
matter  that  envelopes  the  optic  nerve,  around  which 
they  form  a  vascular  net-work.  After  frequent  anas- 
tomoses they  penetrate  the  sclerotic  coat,  near  the 
entrance  of  the  optic  nerve;  some  few  of  them  termi- 
nate in  this  membrane,  the  rest  proceed  between  the 
sclerotic  and  choroid  coats.  After  forming  by  their 
frequent  subdivisions  and  anastomoses  a  kind  of  vascular 
net-work  on  the  exterior  of  the  choroid,  they  pierce  this 
membrane,  and  form  an  expansion  of  more  minute 
vessels  on  its  interior.  Having  arrived  at  the  ciliary 
body,  some  of  them  merely  pass  through  it  to  arrive  at 
the  great  arterial  circle  of  the  iris,  but  by  far  the  great- 
est number  terminate  in  the  ciliary  body,  each  ciliary 

12 


134  CILIARY   ARTERIES. 

process  receiving  so  many  as  twenty  or  thirty  branches : 
these  take  a  tortuous  course  in  the  substance  of  the  pro- 
cesses, and  then,  reuniting  into  larger  and  fewer  branches, 
terminate  behind  the  iris  by  anastomotic  arches.  In 
most  cases  several  of  these  ciliary  arteries  come  from 
some  of  the  principal  branches  of  the  ophthalmic,  and 
not  directly  from  its  trunk.  The  long  ciliary  arteries, 
usually  two  in  number,  pierce  the  sclerotic  coat  a  little 
in  front  of  the  short  ciliary,  and  then  run  from  behind 
forwards  between  the  sclerotic  and  choroid  coats ;  one 
on  the  inner  side,  and  the  other  on  the  outer  side  of  the 
eye.  In  this  course  they  send  a  few  delicate  branches 
to  the  sclerotic  coat,  and  still  fewer  to  the  choroid;  and 
having  arrived  at  the  ciliary  body  they  subdivide  into 
many  branches,  which  communicate  with  the  short 
ciliary  arteries  and  form  an  arterial  circle  at  the  ciliary 
margin  of  the  iris.  From  this  circle  arise  many  small 
branches,  which  j)roceed  towards  the  pupil  in  a  radiated 
manner,  and  then  bifurcate  and  anastomose  with  adjacent 
branches,  so  as  to  form  a  second  arterial  circle  within 
the  first.  From  this  second  circle  arise  smaller  and 
more  numerous  branches  than  from  the  first ;  these  pro- 
ceed in  a  radiated  manner  to  the  pupillary  margin  of  the 
iris,  where  most  of  them  enter  into  the  formation  of  a 
third  arterial  circle  within  the  two  preceding.  In  every 
instance  the  muscular  arteries  give  off  several  ciliary 
branches,  which  have  been  termed  the  anterior  ciliary: 
these  pierce  the  anterior  part  of  the  sclerotic  coat,  and 
communicate  with  the  preceding.  In  speaking  of  the 
vascularity  of  the  iris,  Dr.  Jacob  observes : — "  Much  im- 
portance has  been  attached  by  anatomists  to  the  manner 
in  which  these  radiating  vessels  are  disposed,  in  conse- 
quence of  the  representation  of  Euysch,  who  exhibited 
them  as  fo rmi  ng  a  series  of  inosculations  at  a  short  distance 
from  the  pupil,  since  called  the  lesser  circle  of  the  iris. 


MUSCULAR  ARTERIES.  135 

I  do  not  deny  that  the  vessels  of  the  iris  inosculate  as  in 
other  parts  of  the  body,  but  I  do  not  believe  that  they 
present  this  very  remarkable  appearance,  and  I  suspect 
that  Euysch  exaggerated  what  he  had  seen,  or  described 
from  an  iris  in  vv^hich  the  injection  had  been  extravasated 
and  entangled  in  the  tendinous  cords,  which  I  have 
described  as  extending  from  the  fleshy  bodies  to  the 
margin  of  the  pupil.  The  question  is  fortunately  of  no 
importance.  It  is  sufficient  to  know  that  the  organ  is 
amply  supplied  with  arterial  blood."*  In  the  foetus, 
branches  of  the  long  ciliary  arteries  may  be  traced  to 
the  membrana  pupillaris.  In  the  operation  of  couching, 
the  needle  should  be  made  to  penetrate  the  eye  below 
its  centre,  in  order  to  avoid  these  vessels. 

The  Muscular  arteries  arise  at  the  upper  surface  of 
the  optic  nerve ;  they  are  usually  two  in  number :  the 
inferior  is  a  large  and  constant  branch :  after  its  origin 
it  passes  forwards  between  the  optic  nerve  and  the 
inferior  rectus  muscle :  its  branches  are  distributed  to 
this  muscle,  to  the  inferior  oblique  and  external  rectus 
muscles,  and  to  the  lachrymal  sac.  The  superior  mus- 
cular artery  is  smaller  and  less  constant :  its  branches 
are  principally  distributed  to  the  levator  palpebrse,  and 
to  the  superior  and  internal  recti  muscles;  also  to  the 
superior  oblique  muscle,  to  the  globe  of  the  eye  and 
the  periosteum  of  the  orbit.  As  we  have  already 
mentioned,  the  muscular  arteries  give  off  the  anterior 
ciliary  arteries. 

The  Ethynoidal  arteries  are  two  in  number ;  they  arise 
at  the  inner  surface  of  the  optic  nerve,  and  pass  between 
the  internal  rectus  and  superior  oblique  muscles  of  the 
eye  to  arrive  at  the  internal  wall  of  the  orbit.  The 
posterior  or  larger  enters  the  foramen  orbitale  internum 

*  Todd's  Cyclopaedia. 


136  FRONTAL   ARTERY. 

posterius,  and  sends  several  delicate  branches  to  the 
membrane  of  the  posterior  ethmoidal  cells  :  others  enter 
the  cranium  and  descend  into  the  nasal  fossae  with  the 
filaments  of  the  olfactory  nerve,  to  be  lost  on  the 
mucous  membrane  of  the  nose.  The  anterior  ethmoidal 
artery,  smaller  than  the  preceding,  accompanies  the 
ethmoidal  branch  of  the  nasal  nerve,  and  having  entered 
the  anterior  internal  orbital  foramen,  is  distributed  to 
the  mucous  membrane  of  the  frontal  sinus,  and  anterior 
ethmoidal  cells  and  nasal  fossaB.  The  posterior  branch 
frequently  arises  from  the  lachrymal  or  supra-orbital. 

The  Palpebral  arteries  are  two  in  number;  they  arise 
at  the  inner  surface  of  the  optic  nerve :  the  inferior 
descends  behind  the  tendo  oculi,  and  after  sending  some 
twigs  to  the  lachrymal  sac,  divides  into  two  branches, 
one  of  which  supplies  the  inferior  division  of  the  orbicu- 
laris palpebrarum,  while  the  other  follows  the  adherent 
margin  of  the  lower  tarsal  cartilage,  and  supplies  this 
cartilage,  the  Meibomian  glands,  the  conjunctiva  and 
Bkin.  The  superior  palpebral  artery  arises  a  little  more 
in  front,  and  after  supplying  the  caruncula  lachrymalis, 
is  distributed  in  the  upper  eyelid,  exactly  as  those  of 
the  inferior  artery  are  in  the  lower :  it  anastomoses  ex- 
ternall}^  with  the  lachrymal  and  temporal  arteries. 

The  terminating  branches  of  the  ophthalmic  artery 
are  the  frontal  and  the  nasal. 

The  Frontal  artery,  usually  smaller  than  the  nasal, 
advances  to  the  superior  and  internal  part  of  the  base 
of  the  orbit,  from  which  it  escapes  in  passing  between 
the  tendo  oculi  and  pulley  of  the  superior  oblique  muscle. 
It  then  ascends  on  the  forehead,  between  the  frontal 
bone  and  orbicularis  palpebrarum,  and  subdivides,  to 
supply  this  muscle,  and  the  occipito-frontalis  and  corru- 
gator  supercilii. 

The  Nasal  artery  is  larger  than  the  preceding,  and 


NASAL   ARTERY.  137 

with  it  escapes  from  the  orbit  between  the  tendo  oculi 
and  pulley  of  the  superior  oblique  muscle :  it  then  de- 
scends on  the  side  of  the  root  of  the  nose,  and  supplies 
the  lachrymal  sac,  and  adjacent  muscles,  and  anas- 
tomoses with  the  termination  of  the   labial   or  facial 

Fig.  IS.— Branches  of  Ophthalmic  Artery  given  off  under  the  Superior  Rectus  Muscle. 


1.  Ball  of  the  Kye.  2,  External  Rectus  Muscle.  3,  Insertion  of  Superior  Rectus  Muscle,  cut  and 
turned  forwards.  4,  Tendon  of  Superior  Oblique  Muscle  which  passes  underneath  the  Superior 
Rectus.  5,  Trochlea  or  Pulley  for  Suparior  Oblique  Muscle.  6,  Belly  of  Superior  Oblique  Muscle. 
7,  Superior  Rectus  Muscle  divided.  8.  Optic  Nerve,  a.  Turn  of  Internal  Carotid  Artery  giving  off 
the  Ophthalmic  Artei-y.  b,  Ophthalmic  Artery,  c,  A  twig  to  Superior  Rectus  Muscle,  d,  Muscular 
Branches,  e,  Continuation  of  Ophthalmic  Artery  cut  across,  f,  f,  Some  of  the  short  Ciliary  Arteries. 

artery.  In  many  cases  the  nasal  artery  seems  to  be  per- 
fectly continuous  with  the  angular  branch  of  the  facial. 
In  the  operation  for  extracting  the  eye,  the  trunk  of 
the  ophthalmic  is  divided,  and  its  sheath  prevents  it 
from  retracting  so  as  to  bleed  into  the  cavity  of  the 
cranium ;  the  hemorrhage  into  the  cavity  of  the  orbit 
is  however,  frequently  very  considerable. 

12* 


138  ARTERIES   OP   THE   CEREBRUM. 

After  the  ophthalmic,  the  next  branch  given  off  by 
the  internal  carotid  is  the  choroid  artery. 

The  Choroid  artery  is  a  small  but  constant  branch.  It 
arises  from  the  posterior  part  of  the  internal  carotid, 
and  passes  backwards  and  outwards  towards  the  crus 
cerebri :  in  its  course  it  lies  internal  to  and  under  cover 
of  the  internal  convolution  of  the  base  of  the  middle 
lobe  of  the  brain,  and  external  to  the  posterior  com- 
municating artery :  it  then  enters  the  inferior  cornu  of 
the  lateral  ventricle,  supplies  the  tractus  opticus  and 
crus  cerebri,  the  hippocampus  major,  pes  hippocampi, 
and  corpus  fimbriatum,  and  its  terminating  branches 
are  distributed  to  the  choroid  plexus. 

The  Posterior  communicating  artery  arises  from  the 
internal  carotid  internal  to  the  choroid;  it  is  a  small 
but  constant  branch :  from  its  origin  it  takes  a  direction 
backwards  and  inwards  to  anastomose  with  the  poste- 
rior artery  of  the  cerebrum,  which  is  a  branch  of  the 
basilar  trunk. 

After  having  given  off  the  posterior  communicating 
artery,  the  internal  carotid  divides  into  two  considerable 
branches,  viz.,  the  anterior  and  middle  arteries  of  the 
cerebrum. 

The  Anterior  cerebral  artery  passes  forwards  between 
the  first  and  second  cerebral  nerves,  to  reach  the  great 
longitudinal  fissure ;  it  then  ascends  with  the  corresj^ond- 
ing  artery  of  the  opposite  side  between  the  anterior 
lobes  of  the  brain,  and  in  front  of  the  anterior  part  of 
the  corpus  callosum,  along  the  u]3per  surface  of  which 
it  runs,  and  then  descends  behind  it  so  as  nearly  to 
circumscribe  this  commissure.  The  branches  from  its 
concavity  are  small,  and  distributed  to  the  corpus  cal- 
losum j  those  from  its  convexity  are  more  considerable, 
and  supply  the  internal  surface  of  the  hemispheres. 
The  anterior  arteries  of  the  cerebrum  are  united  by 


ARTERIES   OF   THE   CEREBRUM.  189 

one  or  two  transverse  branches  which  complete  the  circle 
of  Willis  in  front;  these  are  called  the  anterior  com- 
mu7iicating  branches :  when  there  is  but  one,  it  is  a  large 
vessel;  if  more  than  one,  they  are  proportion  ably  small: 
on  the  anterior  communicating  branch  or  branches  the 
ganglion  of  Eibes  is  situated. 

The  Middle  cerebral  artery  is  larger  than  the  preced- 
ing, and  from  its  size  might  be  considered  the  continued 
trunk  of  the  internal  carotid ;  it  sinks  into  the  fissure 
of  Sylvius,  taking  a  direction  outwards  and  backwards. 
It  first  gives  a  great  number  of  branches  to  the  inferior 
part  of  the  brain,  to  the  pia  mater  covering  the  crura 
cerebri,  and  one  or  more  choroid  branches  which  ac- 
company the  choroid  plexus  into,  the  inferior  cornu  of 
the  lateral  ventricle.  It  then  divides  in  the  fissure  of 
Sylvius  into  two  considerable  branches  for  the  anterior 
and  middle  lobes  of  the  brain  -,  these  follow  the  fissure 
outwards  and  backwards,  and  terminate  near  the  poste- 
rior part  of  the  brain  by  numerous  subdivisions:  some 
tortuous  twigs  are  given  off  which  sink  into  the  anfrac- 
tuosities  and  supply  the  pia  mater;  others  appear  to 
perforate  and  surround  the  roots  of  the  olfactory  nerve. 

The  student  should  now  impress  on  his  memory  the 
various  important  parts  with  which  the  internal  carotid 
artery  is  connected,  and  the  manner  in  which  it  may  be 
affected  either  by  disease  or  accident,  in  consequence  of 
its  vicinity  to  them.  Thus,  its  relation  to  the  tonsil 
points  out  the  danger  of  directing  the  knife  too  deeply 
backwards  or  outwards  in  opening  abscesses  of  that 
gland.  Beclard  relates  a  case  in  which  an  itinerant 
quack  destroyed  a  patient's  life  in  this  way.  The 
vicinity  of  this  vessel  to  the  organ  of  hearing  explains 
the  various  derangements  of  the  functions  of  the  latter 
arising  in  consequence  of  an  undue  determination  of 


140  SUBCLAVIAN   ARTERIES. 

blood  to  the  head,  and,  in  certain  cases,  the  hemorrhage 
from  the  ear  which  occurs  in  consequence  of  fractures 
extending  to  the  base  of  the  skull. 

I  am  not  aware  that  there  is  any  case  on  record  of 
aneurism  of  the  trunk  of  the  internal  carotid,  though 
its  branches  are  frequently  the  seat  of  this  disease.  In 
one  case,  however,  in  which  Sir  A.  Cooper  operated  suc- 
cessfully, he  was  of  opinion  that  the  disease  was  in  this 
vessel,  and  not  in  the  external  carotid.* 

Near  the  base  of  the  skull  the  internal  carotid  artery 
in  graminivorous  animals  divides  into  several  minute 
branches,  which  form  a  plexus  of  vessels  called  the  rete 
mirabile  of  Galen  ;  these  subsequently  unite  into  a  single 
trunk,  which  afterwards  divides  into  its  cerebral  branches. 
The  use  of  this  peculiar  plexiform  arrangement  is  to 
prevent  the  brain  from  being  injured  by  the  gravitation 
of  the  blood  whilst  the  animal  is  grazing.  A  similar 
arrangement  of  the  ophthalmic  artery,  "  rete  ophthalmi- 
cum"  has  been  observed  at  the  back  of  the  orbit  in  birds. 

SUBCLAVIAN   ARTERIES. 

These  arteries  are  two  in  number,  a  right  and  left. 
The  right  subclavian  arises  from  the  arteria  innomi- 
nata,  and  the  left  from  the  arch  of  the  aorta:  each  is 
usually  described  as  having  three  stages.  In  the  first 
stage  it  ascends  from  its  origin  to  the  internal  margin 
of  the  scalenus  anticus  muscle;  in  the  second  stage  it 
passes  behind  that  muscle;  and  in  the  third  it  proceeds 
obliquely  downwards  and  outwards,  till  it  arrives  at 
the  lower  margin  of  the  first  rib,  where  it  changes  its 
name  and  becomes  the  axillary  artery.  In  this  course 
the  artery  forms  an  arch,  the  convexity  of  which  looks 
upwards,  and  the  summit  of  which  is  usually  opposite 

«  Med.  and  Chirur.  Trans.,  vol.  i.  p.  229. 


RIGHT   SUBCLAVIAN  ARTERY.  141 

to  the  sixth  cervical  vertebra.  As  the  subclavian 
arteries  differ  in  their  origins,  their  relations  must 
necessarily  differ  in  the  first  stage,  and  therefore  a 
separate  description  will  be  necessary  for  each; 'but  in 
the  second  and  third  stages  their  relations  are  alike. 

First  stage  of  the  Right  Subclavian.  The  right  subcla- 
vian artery  arises  from  the  arteria  innominata  at  the 
superior  outlet  of  the  thorax,  immediately  behind  and 
on  a  level  with  the  upper  portion  of  the  right  sterno- 
clavicular articulation,  corresponding  to  the  interval 
between  the  two  origins  of  the  sterno-cleido-mastoid 
muscle;  it  then  passes  obliquely  upwards  and  out- 
wards, till  it  reaches  the  internal  margin  of  the 
scalenus  anticus  muscle.  In  this  part  of  its  course  it  is 
covered  anteriorly  by  the  integuments,  by  the  platysma 
myoides,  except  in  the  immediate  neighborhood  of  its 
origin,  by  the  clavicular  origin  of  the  stern o-mastoid 
muscle,  and  by  the  cervical  fascia,  forming  the  sheath 
of  this  muscle;  by  the  sterno-hyoid  and  sterno-thyroid 
muscles,  the  former  of  which  is  in  more  intimate  rela- 
tion to  the  artery.  Between  the  sterno-mastoid  muscle 
anteriorly,  and  the  sterno-hyoid  and  sterno-thyroid 
muscles  and  scalenus  anticus  posteriorly,  an  interval 
exists  in  which  we  find  a  quantity  of  loose  areolar 
tissue,  together  with  several  veins,  one  of  which,  some- 
times of  considerable  size,  passes  across  the  posterior 
surface  of  the  inferior  portion  of  the  sterno-mastoid 
muscle,  and  establishes  a  communication  between  the 
anterior  and  external  jugular  veins:  it  is  sometimes 
endangered  in  the  operation  for  wry  neck.  When 
these  parts  have  been  removed,  the  artery  will  be  found 
covered  more  immediately  by  the  internal  jugular  vein 
close  to  its  junction  with  the  subclavian  vein  to  form 
the  right  vena  innominata:  the  union  between  these 
two  veins  usually  takes  place  in  front  of  the  internal 


142  RIGHT   SUBCLAVIAN    ARTERY. 

margin  and  close  to  the  insertion  of  the  scalenus 
anticus  muscle,  in  which  situation  the  commencement 
of  the  vena  innominata  lies  upon  a  plane  anterior  and  a 
little  inferior  to  the  artery :  lower  down,  on  account  of 
their  difference  of  obliquity,  they  become  more  distant, 
the  vein  lying  on  the  outer  side.  The  vertebral  vein  as 
it  is  about  to  terminate  in  the  internal  jugular,  usually 
passes  anterior  to  the  artery.  In  front  of  the  artery 
we  observe  also  the  superior  and  middle  cardiac  nerves 
descending;  and  near  the  origin  of  the  vessel,  the  pneu- 
mogastric  nerve,  and  sometimes  its  recurrent  branch 
(which  in  this  situation  occasionally  begins  to  detach 
itself  from  its  parent  trunk),  are  situated  in  front  of  it. 
Vieussens  describes  a  plexiform  apjDcarance  upon  the 
pneumogastric  nerve  in  this  situation,  corresponding 
to  the  origin  of  the  recurrent,  and  which  he  calls  the 
plexus  gangliformis ;  these  nerves  therefore  pass  be- 
tween the  artery  and  the  vena  innominata.  The 
phrenic  nerve  also  forms  an  anterior  relation  of  the 
subclavian  arteiy:  immediately  after  this  nerve  has 
passed  from  off  the  scalenus  anticus  muscle,  it  gets 
under  cover  of  the  internal  jugular  vein  close  to  its 
junction  with  the  subclavian,  and  insinuates  itself  into 
a  small  interval  which  exists  between  the  origin  of  the 
thyroid  axis  and  the  inner  margin  of  the  muscle;  and  it 
is  in  this  situation  that  the  nerve  lies  in  front  of  the 
right  subclavian  artery  in  its  first  stage:  generally 
speaking,  it  does  not  lie  in  direct  contact  with  the 
artery,  but  is  borne  from  off  this  vessel  by  the  origin  of 
the  internal  mammary  artery,  anterior  to  and  across 
which  the  nerve  usually  passes.  Sometimes  the  phrenic 
nerve  lies  upon  a  plane  posterior  to  the  internal  mam- 
mary artery.  Posteriorly  the  first  stage  of  the  right 
subclavian  artery  is  related  to  the  recurrent  nerve,  in- 
ferior cardiac  nerve,  and  still  farther  back  to  the  trunk 


LEFT    SUBCLAVIAN   ARTERY.  148 

of  the  sympathetic  nerve  where  it  forms  its  inferior 
cervical  ganglion:  this  ganglion  is  situated  behind  the 
artery  close  to  the  origin  of  the  vertebral.  The  longus 
colli  muscle,  with  the  interposition  of  some  loose  areolar 
tissue,  lies  behind  the  artery :  the  apex  of  the  cone  of 
the  pleura  lies  a  little  inferior,  to  the  outside,  and  on  a 
plane  posterior  to  the  vessel. 

First  stage  of  the  Left  Subclavian  artery.  The  left  sub- 
clavian artery  arises  within  the  cavity  of  the  thorax,  from 
the  arch  of  the  aorta,  opposite  to  and  to  the  left  side 
of  the  second  dorsal  vertebra,  and  ascends  slightly  out- 
wards into  the  neck,  till  it  reaches  the  internal  margin 
of  the  scalenus  anticus  muscle,  where  the  second  stage 
commences.  Like  the  common  carotid  artery,  the  first 
stage  may  be  divided  into  two  portions, — a  thoracic  and 
cervical:  the  thoracic  portion  extends  from  the  origin  of 
the  vessel  from  the  arch  of  the  aorta  to  the  tipper  out- 
let of  the  thorax;  and  the  cervical  extends  from  this 
point  to  the  internal  margin  of  the  scalenus  anticus.  In 
its  thoracic  portion  it  is  related,  internally,  to  the  left 
carotid  artery,  which  is  also  situated  on  a  plane  anterior 
to  it;  to  the  oesophagus,  thoracic  duct,  and  recurrent 
nerve,  which  are  on  a  plane  posterior  to  it,  and  to  the 
internal  jugular  vein  and  its  junction  with  the  subcla- 
vian to  form  the  left  vena  innominata:  these  large  veins 
are  also  situated  on  a  plane  anterior  to  the  artery:  ex- 
ternally it  is  related  to  the  top  of  the  left  lung  and  pleura : 
anteriorly  it  is  covered  by  the  sternum,  sterno-clavicular 
articulation ,  and  sterno-hyoid  and  stern o-thyroid  muscles : 
it  is  overlapped  by  the  left  lung  and  pleura,  and  it  is 
crossed  obliquely  near  its  origin  by  the  left  pneumo- 
gastric  nerve :  the  phrenic  nerve  is  anterior  to  and  parallel 
with  the  artery.  The  left  vertebral  vein  lies  anterior 
to  it,  and  on  the  same  plane  we  find  the  origin  of  the 
left  vena  innominata  as  already  described:  posteriorly 


144  SECOND    STAGE    OP   THE    SUBCLAVIAN. 

the  artery  corresponds  to  the  second  dorsal  vertebra  at 
its  origin,  afterwards  to  a  short  portion  of  the  spinal 
column  above  this  vertebra,  to  the  longus  colli  muscle, 
and  to  the  sympathetic  nerve  and  its  inferior  cervical 
ganglion.  The  cervical  portion  is  very  short:  it  has 
anterior  to  it  the  parts  already  mentioned  as  lying  in 
front  of  the  artery  of  the  right  side;  in  front  of  it  also  we 
find  the  internal  jugular  vein,  with  the  vagus  and 
phrenic  nerves.  The  latter  nerve,  at  the  inner  margin 
of  the  scalenus  anticus  muscle,  passes  inwards  towards 
the  middle  line  and  crosses  in  front  of  the  artery  at  the 
termination  of  the  cervical  portion  of  its  first  stage;  and 
the  terminating  portion  of  the  thoracic  duct,  as  it  is 
about  to  enter  the  posterior  part  of  the  left  subclavian 
vein  at  its  junction  with  the  internal  jugular,  lies  anterior 
to  the  artery  in  this  situation. 

From  the  preceding  account  it  follows  that  the  left 
subclavian  artery  differs  in  the  following  respects  from 
the  right:  the  left  subclavian  is  longer  and  proportion- 
ably  more  slender;  it  arises  within  the  cavity  of  the 
thorax,  and  from  the  arch  of  the  aorta;  it  is  situated  at 
the  left  side  of  the  spine,  which  here  forms  a  concavity, 
and  it  is  in  close  relation  with  the  left  side  of  the  second 
dorsal  vertebra :  for  these  reasons  it  lies  much  deeper 
and  farther  removed  from  the  surface  than  the  right: 
its  direction  is  also  more  vertical,  and  consequently 
nearly  parallel  to  the  pneumogastric  and  phrenic  nerves; 
it  is  intimately  connected  with  the  oesophagus  and  tho- 
racic duct  and  left  longus  colli  muscle,  and  it  is  covered 
in  front  and  externally  by  the  left  lung  and  pleura:  the 
internal  jugular  vein  is  nearly  parallel  with  it  internally, 
whilst  at  the  right  side  the  internal  jugular  crosses  in 
front  of  the  subclavian  artery: — lastly,  the  left  subcla- 
vian vein  lies  superior  to  a  considerable  portion  of  the 


THIRD   STAGE   OF   THE    SUBCLAVIAN.  145 

artery  in  its  first  stage,  and  also  internal  to  it;  whilst 
on  the  right  side  the  vein  is  inferior  to  the  artery. 

Second  stage  of  the  Subclavian  arteries. — Each  of  the 
subclavian  arteries  in  its  second  stage  is  covered  ante- 
riorly by  the  integuments,  platy  sma,  cervical  aponeurosis, 
clavicular  origin  of  the  sterno-cleido-mastoid  muscle; 
and  frequently  immediately  behind  this  muscle,  by  the 
transverse  branch  of  communication  between  the  an- 
terior and  external  jugular  veins;  and  by  the  scalenus 
anticus  muscle  which  separates  the  artery  from  the  sub- 
clavian vein;  the  latter  vessel  lying  lower  down,  and 
covering  the  insertion  of  the  muscle.  The  phrenic  nerve 
is  usually  enumerated  amongst  the  anterior  relations  of 
the  subclavian  artery  in  the  second  stage ;  and  from  the 
obliquity  of  its  course  across  the  anterior  surface  of  the 
scalenus  anticus  muscle,  until  it  becomes  related  to  the 
internal  mammary  artery,  it  may  be  considered,  pro- 
perly speaking,  as  an  anterior  relation  both  to  the  first 
and  second  stages  of  the  artery.  Posteriorly  the  artery 
is  related  to  the  apex  of  the  cone  of  the  pleura  and  to 
the  scalenus  posticus  muscle;  the  brachial  plexus  of 
nerves  lies  on  a  plane  posterior  to  the  artery  in  this 
stage,  and  partly  accompanies  the  artery  into  its  third 
stage. 

Third  stage  of  the  Subclavian  arteries.  Each  of  the  sub- 
clavian arteries  in  its  third  stage  takes  a  direction  ob- 
liquely downwards  and  outwards,  and  having  arrived  at 
the  lower  margin  of  the  first  rib  changes  its  name,  and 
becomes  the  axillary  artery.  In  this  course  it  is  covered 
anteriorly  by  the  clavicle  and  subclavian  muscle,  imme- 
diately above  which  it  has  other  important  relations, 
which  we  may  now  proceed  to  study.  On  raising  the 
integuments,  platysma,  and  fascia,  together  with  some 
of  the  supra-clavicular  branches  of  the  cervical  plexus 
of  nerves,  from  off  the  front  of  the  artery,  we  usually 

1:3 


146  THIRD   STAGE   OF   THE   SUBCLAVIAN. 

observe  a  space  between  the  trapezius  muscle  on  the 
outside,  and  the  sterno-mastoid  on  the  inside :  in  some 
cases,  however,  the  fibres  of  these  muscles  meet  at  their 
clavicular  attachments,  so  that  in  order  to  expose  the 
artery  it  becomes  necessary  to  divide  transversely  some 
of  the  fibres  of  the  trapezius.  In  the  deeper  layer  or 
stratum,  we  observe  the  posterior  belly  of  the  omo-hyoid 
muscle  passing  at  first  horizontally  inwards,  and  then 
slightly  upwards  and  inwards  towards  the  larjmx.  A 
triangular  space  is  thus  formed,  bounded  inferiorly  by 
the  clavicle,  internally  by  the  posterior  margin  of  the 
sterno-mastoid  muscle,  and  externally  by  the  posterior 
belly  of  the  omo-hyoid ;  in  this  space,  which  is  called  the 
posterior  inferior  lateral  triangle  of  the  neck,  the  artery 
may  be  felt  emerging  from  behind  the  scalenus  anticus 
muscle  accompanied  by  the  brachial  plexus  of  nerves. 
If  we  were  to  judge  of  the  size  of  this  space  by  the  ap- 
pearance it  presents  in  the  dissected  subject,  we  would 
be  led  into  great  error.  It  is,  in  fact,  hardly  appre- 
ciable while  the  muscles  which  bound  it  preserve  their 
natural  relative  position,  though  dissection  may  make  it 
appear  of  considerable  extent.  The  brachial  plexus  lies 
behind  the  artery,  but  a  large  portion  of  it  j)rojects  at 
its  outer  or  acromial  side.  The  vein  is  situated  on  a 
plane  anterior  to  the  artery,  but  inferior  and  nearer  to 
the  middle  line.  The  anterior  thoracic  nerve  begins  to 
descend  in  front  of  it  in  the  lower  part  of  this  stage  j 
and  lastly,  it  is  crossed  anteriorly  by  the  transversalis 
humeri  artery,  which  runs  in  this  situation  nearly  paral- 
lel to  the  clavicle.  Posteriorly  it  rests  on  part  of  the 
scalenus  posticus,  on  the  inferior  fasciculus  of  the  bra- 
chial plexus,  on  the  origin  of  the  middle  thoracic  nerve, 
which  supplies  the  lesser  pectoral  muscle,  and  on  the 
first  rib.  In  operations  on  the  axillary  artery  and  about 
the   shoulder,   the   arteiy   may   be    easily   compressed 


LIGATURE    OF   THE   FIRST   STAGE    OF   SUBCLAVIAN.    147 

against  the  rib  for  the  purpose  of  preventing  hemor- 
rhage. 

OPERATION  OF  TYING  THE  FIRST  STAGE  OF  THE  SUBCLAVIAN 
ARTERY. 

This  operation  has  been  performed  in  about  ten  cases ; 
in  nine  upon  the  first  stage  of  the  right  subclavian,  and 
in  one  upon  the  first  stage  of  the  left :  all  these  cases 
were  attended  with  fatal  results. 

LIGATURE    OF    THE    SUBCLAVIAN   AETERY    IN    THE    FIRST    STAGE. 


Results  and  Observations. 


No. 

Operator. 

Date  of 
Operation. 

1 

2 

4 

5 

Colles 

Mett 

Hayden  . 
O'Reilly.. 
Partridge 

1811 

1835 
1836 

6 
7 
8 
9 
10 

Listen.... 
Listen.... 
Auvert.... 
Auvert.... 
Rodgers.. 

1845 

Death,  from  hemorrhage,  on  4th  day. 
Death,  from  hemorrhage,  on  18th  day. 
Death,  from  hemorrhage,  on  12th  day. 
Death,  from  hemorrhage,  on  23d  day. 
Death,   from    pericarditis    and    pleuritis,  on 

4th  day. 
Death,  from  hemorrhage,  on  13th  day. 
Death,  from  hemorrhage,  on  36th  day. 
Death,  from  hemorrhage,  on  22d  day. 
Death,  from  hemorrhage,  on  11th  day. 
Death,  from  hemorrhage,  on  15th  day. 


Professor  Colles' s  case.  The  ligature  was  passed  round 
the  artery,  but  not  tightened  till  the  fourth  day,  great 
dyspnoea  and  oppression  about  the  heart  having  oc- 
curred. On  the  ninth  day  the  patient  complained  of 
sensation  of  strangling  and  pain  about  the  heart.  He 
then  became  delirious,  and  died  in  a  few  hours.* 

Mr.  Hayden' s  case.  "  Eliza  Moulang,  aged  57,  unmar- 
ried, and  of  intemperate  habits,  states  that  in  Novem- 
ber, 1834,  she  perceived  a  small  pulsating  tumor,  of  the 
size  of  a  pea,  about  an  inch  and  a  half  below  the  right 
clavicle,  and  at  an  equal  distance  from  the  sternum.  In 
April,  1835,  it  had  increased  to  the  size  of  a  marble,  and 
was  for  the  first  time  attended  with  pain,  which  was  of 


*  Edin.  Med.  and  Surg.  Jour.,  1815. 


148  MR.  hayden's  case. 

a  lancinating  character.  This  recurred  at  intervals  till 
August,  after  which  it  remained  permanently,  being, 
however,  attended  with  increased  severity  at  intervals. 

"August  22,  1835.  She  was  seen  by  Dr.  Ireland, 
Messrs.  Wilmot,  O'Beirne,  and  Hayden,  for  the  first 
time. 

"  Sept.  7.  The  patient  was  admitted  into  the  Angle- 
sey Hospital.  On  examination,  a  large  pulsating  tumor 
was  observed,  situated  internally  to  the  axilla,  parallel 
to  the  upper  edge  of  the  pectoralis  minor,  and  extend- 
ing above  the  clavicle :  it  is  circumscribed,  and  has 
pulsation  referrible  to  its  inferior  part.  There  is  con- 
siderable tension  on  the  upper  portion  of  the  tumor,  the 
size  of  which  can  be  diminished  by  pressure.  Com- 
paring the  clavicle  of  this  side  with  the  opposite  one, 
the  former  appears  somewhat  displaced,  being  pushed 
upwards.  The  arm,  forearm,  and  hand  were  much 
swollen  and  cedematous  some  days  since,  and  ^  bruit  de 
souflflet'  was  audible  over  the  tumor. 

"  The  results  of  stethoscopic  examination  were  not 
unfavorable  in  reference  to  the  operation  for  this  dis- 
ease, which  is  declared  to  be  aneurism  of  the  subclavian 
artery  extending  to  the  scalenus.  She  now  describes 
the  pain  as  darting  through  the  tumor  to  the  back  of 
the  shoulder,  and  down  to  the  elbow.  She  also  com- 
plains of  an  almost  insupportable  sense  of  weight  and 
numbness  in  the  whole  extremity,  although  the  swelling 
of  it  is  inconsiderable." 

Operation.— Oi\  September  15,  1835,  Mr.  Hayden  pro- 
ceeded to  perform  the  operation  in  the  following  man- 
ner : 

'^The  patient  was  placed  on  the  back  upon  a  large 
table,  furnished  with  mattress  and  bolsters;  head 
slightly  depressed,  and  turned  to  the  left  side.     First 


MR.  hayden's  case.  149 

incision,  commenced  nearly  at  the  left  sterno-clavicular 
articulation,  traversed  the  upper  margin  of  the  sternum 
and  clavicle,  and  terminated  beyond  the  posterior  or 
acromial  margin  of  the  sterno-mastoid  muscle,  having 
divided  the  integuments  and  platysma,  including  sub- 
jacent adipose  tissue  of  about  a  quarter  of  an  inch  in 
dej)th.  Second  incision,  commenced  about  four  inches 
above  the  sternum,  a  little  to  the  left  of  the  mesial  line 
of  the  neck,  so  as  to  terminate  by  falling  at  right  angles 
on  the  commencement  of  the  first  incision,  dividing  the 
parts  to  the  same  depth :  two  sides  of  a  triangle  were 
thus  formed,  the  apex  at  the  sternum.  The  flap,  con- 
sisting of  integument,  platysma,  and  adipose  layer,  was 
raised  from  the  apex  upwards  and  outwards :  the  out- 
line of  the  sterno-cleido-mastoid  was  now  very  distinct, 
but  still  covered  by  the  superficial  fascia ;  the  latter  was 
carefully  divided  immediately  above  the  sternum,  cor- 
responding to  the  anterior  edge  and  lower  extremity  of 
the  sternal  portion  of  the  sterno-cleido-mastoid.  A 
director  was  next  introduced  beneath  this  muscle,  the 
fibres  of  which  were  divided  at  about  a  quarter  of  an 
inch  from  the  sternum  and  clavicle,  and  precisely  parallel 
to  its  origin.  The  muscle  was  now  raised  upwards  and 
outwards  with  the  handle  of  a  scalpel :  a  small  vein  was 
here  tied.  In  the  next  stage  of  the  operation,  the  sterno- 
hyoid and  sterno-thyroid  were  divided  upon  a  director. 
Hemorrhage  from  a  small  artery  and  vein  so  inundated 
the  part,  that  it  was  found  necessary  to  secure  them 
before  the  operation  was  proceeded  with.  After  the 
displacement  of  some  cellular  structure  with  a  director, 
the  innominata,  carotid,  and  subclavian  were  felt;  com- 
pression of  the  last-mentioned  vessel  suspended  pulsation 
at  the  wrist  and  tumor.  The  first  part  of  the  subclavian 
was  found  not  involved  in  the  disease,  and,  consequently, 
it  was  decided  that  this  vessel  should  be  tied  in  prefer- 


150  MR.  O'Reilly's  case. 

ence  to  the  innominata,  which  had  been  clearly  exposed, 
and  which,  from  its  direction,  and  being  uninterfered 
with  by  the  clavicle,  seemed  to  offer  much  less  obstacle 
to  the  passage  of  the  ligature;  this  was,  at  first,  at- 
tempted with  an  aneurism-needle,  made  of  silver,  in 
order  that  it  might  be  bent  so  as  to  present  a  degree  of 
concavity  to  the  clavicle,  to  be  determined  by  the  dis- 
placement of  this  bone,  and  the  depth  of  the  artery. 
The  eyed  part  of  the  needle,  for  about  an  inch,  was  made 
to  slide  oif  and  on,  like  the  canula  of  a  trocar,  so  that 
when  the  extremity  of  the  needle  was  brought  around 
the  artery,  the  eyed  portion,  with  the  ligature,  might  be 
withdrawn.  But  when  the  handle  of  the  instrument 
was  depressed,  the  upper  part  slipped  from  the  lower 
before  the  latter  had  passed  under  the  artery.  The 
vessel  was  subsequently  secured  with  Mr.  L'Estrange's 
needle. 

'^  On  the  25th,  though  positively  forbidden,  she  got  out 
of  bed,  and  walked  about  the  room. 

^'  Subsequently,  at  two  o'clock  p.m.,  she  would  not  suffer 
the  nurse  to  pass  the  bed-pan  under  her,  but  got  out  of 
bed;  while  in  the  act  of  doing  so,  and  rising  upon  her 
right  hand  placed  upon  the  bed,  considerable  hemorrhage 
suddenly  set  in. 

*'  The  patient  died  on  the  27th,  twelve  days  after  the 
operation.  The  artery  at  the  side  of  the  ligature  was 
gaping  irregularly  for  three-fourths  of  its  calibre;  the 
remaining  fourth  was  sound,  and  retained  the  ligature."* 

Mr.  O'Beilly's  case. — "  Thomas  Duffy,  aged  39  years,  a 
man  of  robust  frame,  and  twenty  years  employed  as 
helper  in  a  stable,  was  admitted  into  Jervis  Street 
Hospital,  April  15,  1836,  under  the  care  of  Mr.  O'Eeilly, 

*  Lancet,  1837. 


MR.  O'Reilly's  case.  151 

for  aneurism  of  the  right  subclavian  artery.  He  has 
lived  a  life  of  continued  intemperance,  always  drinking, 
but  never  incapable  of  attending  to  his  duty.  The  aneu- 
rismal  tumor  was  distinctly  circumscribed,  of  a  some- 
what oval  shape,  and  measuring  in  transverse  diameter 
two  inches  and  a  half,  and  in  the  vertical  direction  two 
inches.  The  pulsation  could  be  distinctly  felt  in  all  parts 
of  the  tumor,  and  pressure  on  the  subclavian  artery  not 
only  commanded  the  pulsation  of  the  sac,  but  even 
diminished  its  contents  to  the  degree  of  rendering  it 
flaccid ;  finally,  the  bruit  de  soufflet  was  distinctly  audible 
over  all  its  surface.  The  first  time  he  observed  this 
tumor  was  in  February  last,  and  since  that  time  he 
thinks  it  has  made  little  progress.  The  symptoms  he 
complained  of  on  admission  were,  numbness  of  his  fingers 
and  uneasy  sensations  in  his  arm  and  forearm,  with  oc- 
casional cramps,  since  last  Christmas.  For  the  last  eight 
or  nine  weeks  he  has  been  obliged  to  remain  almost  con- 
stantly in  bed,  with  his  arm  extended  from  his  body,  as 
he  suffered  considerable  pain  whenever  he  walked  about 
for  any  time,  or  approached  his  arm  to  his  side;  in  bed, 
however,  with  his  arm  extended,  he  is  quite  free  from 
pain.  His  general  health  did  not  seem  impaired,  and 
his  heart  and  lungs  were  sound,  judging  from  careful 
physical  examination.  On  the  whole  he  appeared  to  be 
a  favorable  subject  for  the  operation  which  was  decided 
on  at  a  consultation  held  with  the  hospital  surgeons : 
the  patient,  being  informed  of  the  nature  and  urgency 
of  his  symptoms,  expressed  his  willingness  to  submit  to 
any  operation  which  would  give  him  relief  Accordingly, 
at  two  o'clock  the  following  day  (September  16),  Mr. 
O'Keilly  proceeded,  with  the  assistance  of  his  colleagues, 
to  perform  the  operation. 

Operation. — The  patient  being  placed  in  Heurteloup's 


152  MR.  O'Reilly's  case. 

bed,  with  his  head  slightly  depressed  and  turned  to  the 
left  side,  so  that  the  light  from  the  sky-light  might  fall 
into  the  deep  space  in  which  the  artery  was  imbedded, 
Mr.  O'Eeilly  commenced  the  operation  in  the  following 
manner,  standing  by  the  patient's  right  side.  He  first 
drew  down  the  integuments  of  the  lower  part  of  the  neck 
over  the  clavicle  with  his  left  hand,  and  then  cut  freely 
on  the  bone,  beginning  his  incision  about  the  centre  of 
the  clavicular  origin  of  the  right  sterno-mastoid  muscle 
and  terminating  it  over  the  trachea,  opposite  the  centre 
of  the  sternal  origin  of  the  left  sterno-mastoid  muscle; 
this  incision  was  about  four  inches  in  length.  The  next 
incision  was  made  through  the  integuments  along  the 
internal  margin  of  the  right  sterno-mastoid,  and  termi- 
nating inferiorly  in  the  centre  of  the  preceding  incision ; 
in  the  same  line  the  superficial  fascia  and  platysma  were 
divided  successively  on  a  director.  The  sternal  origin 
and  internal  half  of  the  clavicular  origin  of  the  right 
sterno-mastoid  muscle  were  divided  transversely  close 
to  the  bone,  and  detached.  On  introducing  the  finger, 
the  line  of  the  carotid  artery  could  be  distinguished,  and 
its  pulsation  felt.  The  deep  fascia  was  next  divided,  and 
a  little  of  the  internal  margins  of  the  sterno-hyoid  and 
sterno-thyroid  muscles,  so  as  to  expose  the  carotid  artery? 
the  sheath  of  which  was  cautiously  opened  by  pinching 
a  small  portion  of  it  with  a  forceps,  and  dividing  the  raised 
portion  of  it  horizontally.  A  blunt  silver  instrument  the 
size  of  a  small  scalpel,  with  a  round  point,  was  used  in 
the  subsequent  steps  of  the  operation.  The  carotid 
artery  being  taken  as  a  guide,  the  subclavian  artery  was 
easily  exposed  lying  at  the  bottom  of  a  very  deep  cavity. 
The  jugular  vein  was  drawn  outwards  by  means  of  a 
curved  spatula,  and  the  pneumogastric  nerve  inwards  by 
a  similar  instrument.  Mr.  L'Estrange's  needle,  armed 
with  a  three-threaded  ligature,  was  passed  round  the 


MODE   OF   PERFORMING   THE    OPERATION.  153 

artery  from  below  upwards  with  facility,  and  without 
disturbing  the  artery  in  its  situation.  The  ligature  being 
tightened  round  the  vessel,  the  edges  of  the  wound  were 
brought  into  contact,  and  retained  so  by  two  strips  of 
adhesive  plaster;  the  operation  occupied  only  twenty- 
five  minutes,  and  not  more  than  a  teaspoonful  of  blood 
was  lost.  Three  hours  after  the  operation  he  felt  com- 
fortable and  well  in  every  respect,  and  heat  and  sensa- 
tion were  the  same  as  in  the  opposite  arm. 

Subsequently  the  patient  had  repeated  hemorrhages, 
and  died  upon  the  twenty-third  day. 

Post-mortem  examination. — The  divided  extremities  of 
the  subclavian  artery  were  patulous  and  separated  nearly 
two  inches  by  coagula :  their  edges  were  jagged  and  ir- 
regular, and  there  seemed  not  to  have  been  the  slightest 
attempt  at  the  reparative  process.  The  distal  end  of  the 
artery  was  of  the  natural  size.  External  to  the  scalenus 
anticus  there  was  a  sudden  enlargement  of  the  artery  or 
aneurismal  swelling,  which  extended  four  inches  to  the 
commencement  of  the  axillary  artery.  On  its  upper  and 
outer  surface  were  stretched  the  brachial  nerves.  About 
an  inch  from  the  commencement  of  the  tumor  the  clavicle 
passed  over  it,  and  made  a  depression  in  it.  The  arteria 
innominata  was  healthy  and  the  heart  natural :  the  trachea 
red  externally,  and  pale  internally,  was  filled  with  a  frothy 
mucus.  A  small  portion  of  the  upper  part  of  the  lung 
was  hepatized.  Bronchitis  of  the  right  lung ;  left  lung 
healthy;  no  eifusion  into  the  thorax.  A  second  aneurism 
about  an  inch  in  diameter  was  found  on  the  axillary 
artery  in  the  first  stage  of  its  course.  The  account  of 
this  case  is  abridged  from  the  notes  of  Mr.  Banon,  one 
of  the  surgeons  of  the  Hospital. 

Mode  of  performing  the  operation. — The  patient  should 
be  placed  in  the  same  position  as  in  that  recommended 


154     LIGATURE  OF  FIRST  STAGE  OF  LEFT  SUBCLAVIAN. 

for  tying  the  arteria  innominata.  The  first  incision 
should  commence  immediately  above  the  sternum,  at  the 
internal  margin  of  the  sterno-mastoid  muscle,  and  be 
continued  horizontally  outward  along  the  anterior  and 
upper  portion  of  the  clavicle  for  the  extent  of  about 
three  inches :  the  second  incision,  about  two  inches  long, 
should  descend  along  the  internal  margin  of  the  same 
muscle,  so  as  to  terminate  infcriorly  in  the  internal 
extremity  of  the  preceding  incision.  The  flap  of  in- 
tegument thus  formed  is  to  be  dissected  up,  and  the 
lower  part  of  the  sterno-mastoid  exposed.  Behind  this 
muscle  a  director  should  be  now  introduced,  on  which 
its  sternal  and  part  of  its  clavicular  origin  should  be 
divided.  In  a  similar  way  the  origin  of  the  sterno- 
hyoid, and  then  that  of  the  stern o-thyroid,  should  be 
cautiously  divided.  By  scraping  through  some  areolar 
tissue  we  may  now  get  a  view  of  the  carotid  artery,  and 
bypassing  the  finger  between  this  vessel  and  the  jugular 
vein,  which  is  situated  more  externally,  the  subclavian 
artery  may  be  felt.  It  is  crossed  near  its  origin  by  the 
pneumogastric  and  recurrent  nerves,  which  must  bo 
drawn  inwards,  and  the  needle  is  to  be  carried  round  it 
from  below  upw^ards  and  inwards,  on  the  inside  of  its 
vertebral  branch.  The  cardiac  filaments  of  the  sympa- 
thetic nerve  should  be  avoided,  and  the  operator  should 
bear  in  mind  the  vicinity  of  the  top  of  the  pleura,  as  it 
may  be  wounded  in  performing  this  operation. 

Operation  of  tying  the  Left  Subclavian  Artery  in  its 
first  stage.  It  has  heretofore  been  generally  considered 
impracticable  to  tie  the  left  subclavian  artery  in  its  first 
stage,  for  the  following  weighty  reasons : — it  extends  for 
a  very  short  distance  indeed  above  the  first  rib,  and  then 
makes  a  short  turn ;  it  is,  moreover,  covered  in  front  in 
this  situation  by  the  subclavian  vein  and  phrenic  nerve. 
Its  deep  situation,  and  almost  vertical  direction,  its  paral- 


LIGATURE  OF  FIRST  STAGE  OF  LEFT  SUBCLAVIAN.      155 

lelism  to  the  carotid  artery  and  pneumogastric  nerve, 
and  its  intimate  connection  with  the  thoracic  duct  and 
pleura,  present  a  complication  of  unusual  difficulties. 
Yelpeau,  however,  seems  to  have  a  different  opinion,  for, 
after  enumerating  the  differences  between  the  two  sub- 
clavian arteries  in  their  first  stage,  he  observes,  "  It  is 
important  to  note  all  these  differences,  as  they  show  us 
that  it  would  be  much  less  dangerous  to  apply  a  ligature 
here  than  on  the  right  side,  because,  being  placed  at  a 
greater  distance  from  the  origin  of  the  vessel,  the  adhe- 
sive clot  would  form  without  difficulty.  It  would  likewise 
be  easier  in  its  execution,  for  the  nerves  do  not  cross  it 
as  on  the  right,  but  descend  parallel  to  its  direction  into 
the  chest,  and  might  be  readily  separated.  Nevertheless, 
it  must  be  admitted  that  almost  all  these  advantages 
are  counterbalanced  by  the  greater  depth,  and  almost  ver- 
tical direction,  of  the  artery.  It  must  be  remembered 
also  that  the  pleura  is  more  intimately  related  to  the 
first  stage  of  the  left  subclavian  than  at  the  right  side, 
a  circumstance  which  materially  adds  to  the  danger  of 
this  operation  and  to  the  difficulties  in  isolating  the 
artery." 

The  left  subclavian  artery  in  its  first  stage  was  tied  in 
the  living  individual  by  Dr.  Eodgers,  of  New  York.  "  The 
patient  was  a  man,  aged  forty-two,  who,  in  consequence 
of  lifting  a  heavy  weight  upwards  of  a  month  previously, 
suddenly  became  the  subject  of  aneurism  of  the  left  sub- 
clavian artery.  The  operation  was  performed  on  the 
14th  of  October,  1845.  Two  incisions  were  made ;  one, 
three  inches  and  a  half  in  length,  along  the  inner  border 
of  the  sterno-cleido-mastoid  muscle,  terminating  at  the 
sternum,  and  dividing  the  integuments  and  platysma- 
myoid  muscle  -,  and  the  other,  two  inches  and  a  half  in 
length,  extending  horizontally  over  the  inner  extremity 
of  the  clavicle,  the  two  meeting  at  a  right  angle  near 


156 


LEFT    CAROTID    ANJ>  LEFT    SUBCLAVIAN. 


Fig.  19.- 


-Some  of  the  relations  of  the  Left  Carotid  and  Left  Subclavian  Arteries  in 
the  cervical  portion  of  their  first  stage. 


A,  Left  Common  Carotid  Artery.  B.  Left  Subclavian  Artery.  C,  Internal  Jugular  about  to  join  D, 
the  Left  Subclavian  Vein ;— the  Jugular  and  Subclavian  Veins  displaced  outwards.  K,  Anterior 
Jugular  Vein  in  it3  course  behind  the  Stemomastoid  Muscle.  F,  Deep  Cervical  Fascia.  G,  Left 
Sterno-mastoid  Muscle  divided  and  separated  from  g,  g,  its  Siei-nal  and  Clavicular  origins.  H,  Left 
Sterno-hyoid  Muscle  cut.  I,  Left  Sternothyroid  Muscle  cut.  K,  Right  Sternohyoid  Muscle.  L, 
Right  Sterno-mastoid  Muscle.  M,  Trachea.  N,  Projection  of  the  Thyroid  Cartilage.  O,  Hollow, 
internal  to  Sterno-mastoid  Muscle.  P.  Situation  where  the  Subclavian  Artery  passes  behind  the 
Clavicle.  Q,  Sternal  end  of  Left  Clavicle.  R,  Right  Sternothyroid  Muscle,  b,  Left  Pueumogastric 
Nerve,   d,  Left  Anterior  Scalenus  Muscle,    f,  f,  Layers  of  the  Cervical  Fascia. 


DR.    RODGERS'S   CASE.  157 

the  trachea.  Several  small  veins  having  been  ligated,  and 
the  flap  thus  formed  dissected  u^,  the  sternal  portion 
with  half  of  the  clavicular  of  the  mastoid  muscle  was 
divided  upon  a  grooved  director,  a  procedure  which 
fully  brought  into  view  the  sterno-hyoid  and  omo-hyoid 
muscles  and  the  deep-seated  jugular  vein,  all  covered  by 
the  cervical  fascia.  A  part  of  the  aneurismal  sac  was 
also  in  sight,  overlapping  a  considerable  portion  of  the 
anterior  surface  of  the  scalene  muscle,  upon  which  the 
operator  could  distinctly  feel  the  phrenic  nerve.  By 
digging  with  the  handle  of  the  knife,  and  fingers,  the 
deep  cervical  fascia  was  now  divided  close  to  the  inner 
edge  of  the  scalene  muscle,  when,  after  a  little  search, 
the  subclavian  artery  was  easily  discovered  as  it  passed 
over  the  first  rib,  pressure  upon  this  portion  readily 
arresting  the  pulsation  of  the  tumor.  The  next  step  of 
the  operation  consisted  in  passing  the  ligature  around 
the  vessel  without  injury  to  the  pleura  and  thoracic 
duct,  but  this  proved  to  be  one  of  extreme  difiiculty, 
owing  to  the  great  narrowness  and  depth  of  the  wound, 
the  latter  nearly  equalling  the  length  of  the  forefinger. 
This,  however,  was  at  length  successfully  accomplished, 
by  means  of  an  aneurismal  needle  with  a  movable  point, 
carried  from  below  upwards.  The  moment  the  ligature 
was  tied,  all  pulsation  in  the  tumor  ceased,  and  the 
patient,  if  not  entirely  comfortable,  made  no  complaint 
of  any  kind. 

The  wound  became  somewhat  erysipelatous  after  the 
operation,  but,  on  the  whole,  the  patient  got  on  well 
until  the  26th  of  October,  when,  on  changing  his  posi- 
tion in  bed,  hemorrhage  supervened,  and,  continuing  to 
recur  at  various  intervals,  destroyed  him  on  the  fifteenth 
day.  On  dissection,  the  wound  was  found  to  be  filled 
with  clotted  blood,  beneath  which  the  arterj^  had  been 
completely  divided  by  the  ligature,  which  lay  loose  close 

14 


158    LIGATURE  OP  SECOND  STAGE  OF  THE  SUBCLAVIAN. 

by.  The  stump  of  the  subclavian,  between  the  aorta 
and  the  point  of  ligation,  was  about  an  inch  and  a  quarter 
in  length,  and  thoroughly  impervious  to  air  and  liquids, 
its  calibre  being  occupied  by  a  solid  and  firmly  adherent 
coagulum.  The  distal  extremity  of  the  subclavian  con- 
tained a  soft  imperfect  clot,  while  the  vertebral  artery 
which  was  given  off  immediately  at  the  site  of  the  liga- 
ture, was  almost  patulous,  and  had  evidently  been  the 
seat  of  the  hemorrhage  which  caused  the  patient's  death. 
The  aneurismal  sac,  the  size  of  a  small  orange,  was  com- 
pletely blocked  up  with  coagula :  the  thoracic  duct  was 
uninjured,  but  the  pleura  at  the  bottom  of  the  wound  was 
found  to  be  extensively  lacerated^  and  through  the  opening 
thus  formed  a  large  quantity  of  blood  had,  passed  into  the 
left  cavity  of  the  chest."^ 

Operation  of  tying  the  Subclavian  artery  in  its  second 
stage.  This  operation  is  not  generally  practised  in  this 
country,  both  on  account  of  its  supposed  difficulty  and 
the  dangerous  consequences  apprehended.  The  difficulty 
has,  however,  been  exaggerated.  With  moderate  care 
the  scalenus  anticus  muscle  may  be  divided  without  in- 
juring the  jugular  vein,  phrenic  nerve,  or  scapular 
branches  of  the  thyroid  axis ;  and,  though  it  be  not  de- 
sirable to  tie  an  artery  so  close  to  one  of  its  branches, 
yet  there  is  every  reason  to  believe  that  the  absence  of 
coagulum  on  the  cardiac  side  of  the  ligature  does  not 
necessarily  preclude  the  possibility  of  success.  Still  it 
must  be  borne  in  mind,  that  the  top  of  the  pleura  lies 
close  to  and  immediately  behind  the  artery  in  this  situa- 
tion, and  may  be  injured  by  the  aneurism-needle ;  and 
again,  the  ligature  in  this  stage  would  include  the  artery 
close  to  the  origin  of  the  superior  intercostal  and  cervi- 
calis  profunda. 

*  Gross's  System  of  Surgery,  vol.  i.  p.  909. 


LIGATURE  OP  THIRD  STAGE  OP  THE  SUBCLAVIAN.     159 

The  operation  was  originally  suggested  by  Dupuytren,* 
and  Dr.  Auchinloss  performed  it  on  the  left  subclavian 
artery.f  ^ 

Operation  of  tying  the  Subclavian  artery  in  its  third 
stage.  This  operation  has  been  frequently  performed 
for  aneurism  and  wounds  of  the  axillary  artery.  Mr. 
Eamsden  first  tied  the  artery  in  the  year  1809 ;  since 
then  it  has  been  frequently  the  subject  of  successful 
operation.  Dr.  Post  of  New  York  first  performed  this 
operation  with  success  in  1817,  and  Mr.Liston  afterwards, 
in  the  year  1820:  finding  the  artery  diseased  at  the 
commencement  of  its  third  stage,  Mr.  Liston  cut  across 
the  external  half  of  the  scalenus  anticus  muscle,  and  in 
this  situation  included  the  artery  in  a  ligature.J  In  this 
city  the  operation  in  the  third  stage  has  been  performed 
by  Professor  Colles,  Professor  Porter,  Dr.  Hutton,  Mr. 
Ellis,  and  others. 

The  following  method  is  recommended  in  order  to 
expose  this  vessel :  the  patient  should  be  placed  lying  on 
a  table  of  convenient  height,  with  the  shoulders  elevated, 
so  that  the  light  may  fall  directly  on  the  parts  exposed. 
The  first  incision  should  commence  at  the  external  margin 
of  the  sterno-mastoid  muscle,  immediately  above  the 
clavicle,  and  be  continued  transversely  outwards  for  the 
extent  of  about  three  inches.  The  platysma  myoides 
and  fascia  may  now  be  divided  on  a  director  to  the  same 
extent.  Some  operators  prefer  dividing  these  three  layers 
at  once  by  cutting  down  on  the  clavicle  after  having 
previously  pushed  the  shoulder  upwards ;  such  an  incision 
will  of  course  be  above  the  clavicle  when  the  shoulder  is 
again  depressed  in  order  to  continue  the  operation.  In 
many  cases,  however,  of  large  aneurism,  these  motions 

*  Lemons  Orales,  vol.  iv.  p.  530. 

f  See  Edin.  Med.  and  Surg.  Jour.,  vol.  xlv. 

X  Edin.  Med.  and  Surg.  Jour.,  No.  64, 


160     LIGATURE  OF  THIRD  STAGE   OF  THE  SUBCLAVIAN. 

of  the  shoulder  would  be  impossible.  The  lips  of  the 
wound  should  now  be  separated  by  retractors,  and  any 
fibres  of  the  trapezius  muscle  which  advance  beyond  its 
outer  angle  should  be  carefully  divided  on  a  director. 
The  external  jugular  vein  which  now  presents  itself 
should  be  drawn  to  the  sternal  extremity  of  the  wound : 
if,  however,  it  should  happen  to  lie  more  towards  the 
acromial  side,  it  should  be  drawn  outwards;  lastly,  if  it 
cross  the  centre  of  the  incision,  or  if  there  be  a  second 
external  jugular  in  this  situation,  it  may  be  necessary  to 
include  it  in  two  fine  ligatures  and  divide  the  vessel 
between  them.  A  plexus  of  veins,  which  usually  next 
presents  itself,  should  be  separated  with  the  handle  of 
the  scalpel,  but  injured  as  little  as  possible,  as  the  further 
steps  of  the  operation  will  be  considerably  obscured  by 
the  blood  which  these  vessels  throw  out.  The  omo-hyoid 
muscle  may  be  observed  a  little  above  the  clavicle,  from 
which  point  it  ascends  obliquely  upwards  and  inwards. 
In  a  case  operated  on  by  the  late  Professor  Todd,  this 
muscle  lay  below  the  clavicle,  and  it  became  necessary 
to  draw^it  up  and  divide  it  before  the  artery  could  be 
exposed.  Connecting  the  margin  of  this  muscle  to  the 
adjacent  margin  of  the  scalenus  anticus,  a  strong  fascia 
will  be  found,  through  which  the  operator  should  cau- 
tiously tear  with  his  nail.  The  finger  may  now  be  passed 
behind  the  outer  margin  of  the  scalenus  anticus  muscle, 
in  order  to  search  for  the  subclavian  artery.  It  should 
be  borne  in  mind  that  the  transversalis  humeri  artery 
lies  nearly  in  front  of  the  subclavian^  passing  horizon- 
tally either  behind  or  immediately  above  the  clavicle; 
the  circumstances  of  its  smaller  size,  and  its  crossing  in 
front  of  the  scalenus  anticus  muscle,  may  assist  in  dis- 
tinguishing it.  The  difficulty  of  at  once  finding  the  sub- 
clavian has,  however,  occasionally'  been  found  greater 
than  would  have  been  expected  a  priori:  the  artery 


WARDROP'S    OPERATION    ON    THE    SUBCLAVIAN.        161 

when  exposed  frequently  contracts  and  its  pulsation 
ceases;  the  margin  of  the  scalenus  anticus  is  rendered 
indistinct  by  its  connection  with  fascia,  and  the  welling 
of  blood,  the  depth  of  the  artery  and  alteration  of  the 
relative  position  of  the  part  caused  by  the  aneurismal 
tumor  pushing  up  the  clavicle,  together  with  an  enlarge- 
ment of  one  or  two  lymphatic  glands,  present  difficul- 
ties that  require  the  greatest  presence  of  mind,  judgment, 
and  knowledge  of  anatomy  on  the  part  of  the  surgeon. 
It  has  been  suggested  by  Professor  Ilargrave,  under 
these  circumstances,  as  well  as  for  the  purpose  of  allow- 
ing the  artery  to  be  gently  relaxed  after  having  been 
secured,  to  saw  through  the  clavicle.*  Cruveilheir  has 
also  advocated  a  similar  practice.  Dupuytren  recom- 
mends that  some  of  the  outer  fibres  of  the  scalenus  an- 
ticus muscle  should  be  divided  if  necessary,  and  this 
may  be  easily  effected  without  injuring  the  phrenic 
nerve.  We  have  seen  that  Mr.  Liston  was  obliged  to 
divide  the  fibres  of  this  muscle. 

The  subclavian  artery  has  been  tied  for  aneurism  of 
the  arteria  innominata  in  conformit}^  with  the  recom- 
mendation of  Mr.  Wardrop.  We  have  seen  that  the 
carotid  artery  has  also  been  tied  upon  the  same  prin- 
ciple. A  few  words  of  explanation  as  to  the  rationale 
of  this  operation,  called  the  application  of  the  *'  distal 
ligature,^'  may  be  useful  at  the  present  stage  of  the  sub- 
ject. It  will  be  remembered  that  the  Hunterian  opera- 
tion for  the  cure  of  aneurism  consisted  in  the  application 
of  a  ligature  upon  the  artery  between  the  heart  and  the 
aneurismal  sac ;  the  object  held  in  view  in  this  operation 
was  the  prevention  of  the  direct  flow  of  blood  through 
the  main  channel  into  the  tumor;  this  was  followed  by 


*  Hargrave's  Operative  Surgery,  p.  44,  and  Dublin  Quarterly  Journal 
for  February,  1849,  p.  5.3. 

14* 


162        WARDROP'S   OPERATION   ON   THE   SUBCLAVIAN. 

the  coagulation  of  its  contents,  and  ultimately  by  its 
entire  absorption.  The  mode  of  operating  for  aneurism, 
known  by  the  name  of  the  distal  ligature,  was  originally 
suggested  by  Brasdor,  and  was  recommended  by  him  in 
cases  where  no  branch  would  intervene  between  the  liga- 
ture and  the  sac,  and  where  the  surgeon  could  not  well 
tie  the  artery  between  the  tumor  and  the  heart.  It  w^as 
supposed  that,  if  no  branch  originated  from  the  aneurism, 
or  from  the  artery  either  above  or  below  the  aneurism, 
the  blood  would  coagulate  in  the  tumor,  and  that  a  cure 
would  be  accomplished  by  the  absorption  of  the  coagu- 
lum  and  the  subsequent  contraction  and  absorption  of 
the  sac.  The  principle  ujDon  which  a  cure  is  expected 
to  follow  this  mode  of  operating  is  the  same  as  that  upon 
which  varicose  veins  of  the  leg  are  treated,  by  making 
pressure  upon  the  superior  part  of  the  saphena  vein  : 
the  blood  becomes  obstructed  in  the  vessel,  a  coagulum 
is  formed,  and  an  obliteration  of  the  venous  channel  is 
accomplished.  Mr.  Wardrop  reports  the  successful  ter- 
mination of  the  case  in  which  he  performed  the  opera- 
tion already  mentioned.  He  was,  moreover,  induced, 
from  various  considerations,  to  apply  the  principle  sug- 
gested by  Brasdor  to  the  cure  of  aneurismal  tumors  of 
certain  arteries,  by  applying  a  ligature,  not  upon  the 
artery  itself y  hut  upon  one  of  the  branches  of  the  diseased 
trunk:  he  imagined  that  this  would  be  sufficient  to 
diminish  the  momentum  of  the  circulation  through  the 
aneurism,  and  so  produce  a  consolidation  of  the  tumor 
and  subsequent  cure  of  the  disease.  In  1827  he  was  con- 
sulted by  a  patient,  a  female,  who  had  an  aneurism  of 
thearteriainnominata:  the  tumor  had  advanced  into  the 
neck,  and  made  such  pressure  upon  the  carotid  artery 
as  to  prevent  the  circulation  of  the  blood  through  it. 
He  was  of  opinion  that  a  ligature  placed  now  upon  the 
subclavian  artery  alone  would  effect  a  consolidation  of 


MR.  wickham's  case.  163 

the  aneurismal  tumor;  accordingly,  in  the  month  of 
July  of  that  year,  he  tied  this  artery  in  its  third  stage. 
There  was  no  secondary  hemorrhage :  the  operation  was 
unattended  by  any  unfavorable  results.  On  the  twenty- 
second  day  the  ligature  came  away  and  the  wound 
healed.  The  pulsation  in  the  common  carotid  arterj-, 
however,  returned  upon  the  ninth  day.  Some  months 
after  the  operation,  two  newly  formed  swellings,  which 
were  engrafted  upon  the  oldone,  had  made  their  appear- 
ance, and  the  aneurism  continued  to  enlarge.  Symptoms 
of  bronchial  inflammation  made  their  appearance,  diar- 
rhoea set  in,  general  anasarca  took  place,  and  she  died 
twenty-three  months  after  the  performance  of  the  ope- 
ration. 

Mr.  Wickham,  Surgeon  to  the  Winchester  Hospital, 
was  consulted  by  a  patient,  a  man  aged  fifty-five  years, 
laboring  under  an  aneurism  of  the  arteria  innominata. 
On  September  25,  1839,  a  ligature  was  placed  on  the 
carotid  artery  immediately  above  the  omo-hyoideus 
muscle;  the  ligature  came  away  on  the  fourteenth  day 
after  the  operation.  It  was  determined  that  the  sub- 
clavian artery  should  be  tied  shortly  afterwards,  but 
the  patient  left  the  hospital  contrary  to  advice  and  re- 
mained out  for  a  considerable  length  of  time.  On  his 
read  mission,  however,  the  subclavian  artery  was  tied  in 
its  third  stage;  the  tumor  increased  in  size,  hemorrhage 
took  place,  and  the  patient  ultimately  sank.* 

The  subclavian  and  carotid  were  both  tied  in  their 
first  stage  upon  the  same  patient  by  Dr.  Hobart,  of  Cork, 
in  the  year  1839.  The  case  was  supposed  to  be  one  of 
aneurism  of  the  arteria  innominata,  and  the  patient  a 
female  of  about  twenty-five  years  of  age.  On  a  consult- 
ation being  held  of  the  principal  surgeons  in  Cork,  it 

*  Med.  Chirur.  Trans.,  vol,  xxiii. 


164  DR.  hobart's  case. 

was  unanimously  agreed  that,  in  order  to  give  the 
patient  a  chance,  the  distal  operation  should  be  per- 
formed. Accordingly,  in  the  presence  of  a  large  body 
of  medical  men,  among  whom  were  Sir  James  Pitcairne 
and  other  military  surgeons,  also  Drs.  Bullen,  Murphy, 
Howe,  &c.,  Dr.  Hobart  made  a  Y-shaped  incision,  one 
leg  of  the  Y  being  parallel  to  each  of  the  vessels,  and 
without  much  difficulty  came  down  on  the  arteries  :  the 
subclavian  was  tied  between  the  innominata  and  where 
it  gives  off  its  first  branches,  and  the  carotid  about  an 
inch  above  its  origin.  The  patient  was  then  removed 
to  bed.  On  the  fourteenth  day  after  the  oj^eration,  the 
ligature  came  away  from  the  subclavian  artery  without 
any  hemorrhage,  and  every  thing  promised  a  favorable 
result,  especiallj^  as  the  pulsation  in  the  tumor  had  quite 
disappeared.  On  the  sixteenth  day,  the  patient,  a 
woman  of  violent  temper,  had  a  quarrel  with  the  nurse, 
when  she  jumj)ed  out  of  bed,  seized  a  pillow  and  some 
books  and  threw  them  at  her;  while  making  these 
exertions,  hemorrhage  set  in  from  the  carotid,  and  the 
patient  died  shortly .  after.  On  a  post-mortem  exami- 
nation being  made,  the  arteria  innominata  was  found 
healthy,  and  the  circulation  through  it  had  not  been 
stoj)ped,  but  a  pyriform  tumor  which  grew  from  the 
arch  of  the  aorta  to  the  left  of  the  innominata,  had 
overlapped  and  to  a  certain  extent  had  pressed  upon 
that  vessel.  It  was  found  that  'perfect  union  had  taken 
place  where  the  ligature  had  been  applied  on  the  subclavian^ 
but  a  small  opening  was  found  in  the  carotid,  through 
which  the  hemorrhage  had  occurred.  The  tumor  was 
filled  with  a  firm  coagulum.  The  parts  were  carefully 
removed  by  Dr.  Wherland,  and  are  preserved  in  the 
museum  of  the  College  Buildings,  Warren's  Place, 
Cork. 


CAROTID   ARTERIES. 


165 


IKg.  20.— Dissection  of  Right  Common  Carotid,  External  and  Internal  Carotid, 
Subclavian  and  Axillary  Arteries. 


A,  A,  Common  Carotid  Artery.  B,  External  Carotid  Artery.  C.  Internal  Carotid  Artery.  D,  Sub- 
clavian Artery  in  its  tirst  stage.  E,  Subclavian  Artery  in  its  third  stage.  P,  Axillary  Artery  in  its 
first  stage.  G,  Axillary  Artery  in  its  third  stage.  H.  Brachial  Artery.  I,  Inferior  Thyroid  Artery. 
K,  Thyroid  Axis.  P,  Thoracicoacromial  Artery.  S,  Sub-scapular  Anery.  a,  Superior  Thyroid 
Artery,  b.  Lingual  Artery,  c,  Facial  Artery,  f,  f,  f.  Occipital  Artery,  g.  Posterior  Auris  Artery, 
h,  Transversalis  Faciei  Artery,  i.  Small  branch  to  Zygomatic  muscles,  m,  Ascendens  Colli,  which 
in  this  case  came  directly  from  the  Thyroid  Axis,  n,"  Supra-scapular  Artery,  q.  Muscular  branch, 
r.  Long  Thoracic  Artery.  1.  Insertion  of  Stcrno-mastoid  Muscle.  2,  Posterior  surface  of  External 
Ear.  3,  Masseter  Muscle.  4,  Zygomalicus  Major  Muscle.  5,  Steno's  Duct  cut.  6,  Depressor  Anguli 
Oris.  7.  Splenius  Capitis  cut.  8,  Levator  Anguli  Scapulae.  9,  Os  hyoides.  10,  Mylo-hyoid  Muscle. 
11,  Scalenus  Medius  and  Posticus.  12.  Scalenus  Anticus.  13,  Anterior  belly  of  Onio-hyoid  Muscle. 
U,  Trapezius.  15.  16,  Muscular  Artery.  17.  Posterior  belly  of  Omohyoid  Muscle.  18,  18,  18,  Brachial 
Plexus.  19,  Posterior  Scapular  Artery  which  in  this  case  was  given  off  by  the  Subclavian.  20, 
Trachea.  21,  22,  Deltoid  Muscle.  23,  Clavicular  portion  of  Right  Pectoralis  Major  cut  away.  24, 
Suhclavius  Muscle.  25,  Sternal  portion  of  Right  Sterno-mastoid  Muscle  cut.  26,  Termination  of 
Pectoralis  M.ijor.  27,  31,  Biceps.  28,  Coraeo-brachialis.  29,  Pectoralis  Minor.  30,  Intercostals. 
82.  Triceps.  33,  Latissimus  Dorai  drawn  outwai-d.  34,  35,  Axillary  branches.  36,  36,  Sternal  portion 
of  Pectoralis  Major  Muscle. 


166  VERTEBRAL  ARTERY. 

The  branches  of  the  subclavian  artery  are  similar  on 
the  right  and  left  sides':  they  are  the  following : 

Yertebral.  Thyroid  Axis. 

Internal  Mammary.  Cervicalis  Profunda. 

Superior  Intercostal. 

The  vertebral,  internal  mammary,  and  thyroid  axis 
come  off  from  the  artery  in  \i^  first  stage;  the  cervicalis 
profunda  and  superior  intercostal  come  off  in  the  secojid 
stage.  The  subclavian  seldom  gives  off  any  branch  in 
its  third  stage;  occasionally,  however,  the  posterior 
scapular  arises  in  this  situation  and  pierces  the  brachial 
plexus  of  nerves  in  order  to  arrive  at  its  destination. 
Prof.  Hargrave  has  seen  the  internal  mammary  artery 
arise  on  the  outside  of  the  scalenus  anticus  muscle. 

The  Yertebral  Artery  is  usually  the  first  branch  of 
the  subclavian,  and  comes  off  from  the  superior  and 
posterior  portion  of  that  vessel :  it  may  be  divided  into 
four  stages.  In  the  first  it  ascends  almost  vertically  in 
the  neck  as  high  as  the  foramen  in  the  transverse  pro- 
cess of  the  sixth  cervical  vertebra:  in  the  second  it 
passes  through  the  foramina  of  the  transverse  processes; 
in  the  third  it  passes  horizontally  inwards,  behind  the 
occipito-atlantoid  articulation;  and  in  the  fourth  it 
passes  obliquely  upwards,  forwards,  and  inw^ards,  on  the 
side  of  the  medulla  oblongata. 

In  its  first  stage,  at  its  origin  from  the  subclavian 
artery,  it  lies  a  little  to  the  outside  of  the  carotid,  and 
passes  upwards  and  backwards,  situated  in  an  angular 
space  formed  between  the  scalenus  anticus  muscle  exter- 
nally, and  the  longus  colli  internally.  In  this  course  it 
lies  on  the  inferior  cervical  ganglion  of  the  sympathetic 
nerve,  and  is  covered  in  front  by  the  vertebral  vein,  and 
by  the  inferior  thyroid  ^rtery,  which  crosses  its  course 
and  separates  it  from  the  common  carotid. 


VERTEBRAL   ARTERY.  167 

In  its  second  stage  it  enters  the  foramen  in  the  trans- 
verse process  of  the  sixth  cervical  vertebra,  and  passes 
through  the  corresponding  foramina  of  the  vertebrae 
above  it.  In  this  course  it  is  accompanied  by  the  ver- 
tebral vein  and  by  a  plexus  of  branches  given  off  from 
the  inferior  cervical  ganglion  :  it  ascends  between  the 
anterior  and  posterior  intertransverse  muscles,  and  in 
front  of  the  anterior  branches  of  the  cervical  nerves, 
along  each  of  which  it  sends  a  small  artery  to  the 
spinal  marrow;  these  small  branches  are  called  the 
lateral  spinal  arteries.  It  also  gives  off  some  muscular 
branches  in  its  course  which  anastomose  with  the  cer- 
vicalis  superficialis  and  ascehdens  colli  arteries.  After 
the  vertebral  artery  has  passed  through  the  foramen 
in  the  transverse  process  of  the  second  vertebra,  it 
inclines  upwards  and  outwards  to  reach  that  of  the 
atlas,  which  extends  farther  outwards  than  the  trans- 
verse process  of  the  dentata ;  in  its  course  from  the  one 
process  to  the  other  it  describes  a  curve,  the  convex- 
ity of  w^hich  looks  downwards,  backwards,  and  out- 
wards. 

In  itfl  third  stage  it  is  horizontal.  After  the  artery 
has  passed  through  the  transverse  process  of  the  atlas, 
it  is  placed  at  the  inner  side  of  the  rectus  capitis  late- 
ralis muscle,  which  here  separates  it  from  the  occipital 
artery  which  lies  at  the  outer  side  of  the  muscle :  from 
this  point  the  vessel  is  directed  at  first  backwards  and 
inwards,  and  then  winds  forwards  and  inwards  to 
pierce  the  posterior  occipito-atlantoid  ligament.  In 
this  course,  its  concavity,  turned  forwards,  embraces 
the  articulation  between  the  atlas  and  the  condyle  of 
the  occipital  bone :  its  convexity,  turned  backwards, 
may  be  seen  in  a  triangular  space,  bounded  internally 
or  towards  the  middle  line  by  the  rectus  capitis  pos- 
ticus  major   muscle,  above   by  the   obliquus   superior 


168  BRANCHES  OP  THE  VERTEBRAL. 

muscle,  and  below  by  the  obliqims  inferior.  Inferiorly 
it  lies  in  a  groove  on  the  upper  surface  of  the  poste- 
rior arch  of  the  atlas,  but  is  here  separated  from  the 
bone  by  the  interposition  of  the  ganglionic  dilatation 
of  the  tenth  or  sub-occipital  nerve :  whilst  resting  on 
this  portion  of  the  atlas,  the  horizontal  curve  of  the 
artery  is  situated  on  a  plane  superior  and  j)Osterior 
to  the  first  cervical  nerve  as  it  escapes  from  the  spinal 
canal  behind  the  inferior  oblique  process  of  the  atlas. 
Superiorly  the  vertebral  artery  is  covered  by  a  produc- 
tion of  the  posterior  occipito-atlantoid  ligament,  which 
converts  the  groove  upon  the  atlas  for  the  artery,  into 
a  canal.  In  this  stage  the  artery  gives  off  minute 
branches  which  anastomose  with  others  from  the  occi- 
pital and  cervicalis  profunda  arteries. 

In  its  fourth  stage  the  vertebral  artery  pierces  the 
dura  mater  beneath  the  insertion  of  the  first  tooth  of 
the  ligamentum  dentatum,  passes  upwards  and  inwards 
upon  the  front  of  that  structure,  which  consequently 
separates  the  artery  from  the  spinal  accessory  nerve 
as  it  is  passing  upwards  and  outwards  behind  the  liga- 
ment. The  artery  then  runs  either  before  or  through 
the  midst  of  the  fibrils  composing  the  ninth  nerve,  ap- 
plies itself  to  the  side  of  the  medulla  oblongata,  and 
afterwards,  getting  in  front  of  this  body,  it  joins  the 
vertebral  of  the  opposite  side  at  the  posterior  inferior 
margin  of  the  pons,  and  forms  the  basilar  trunk. 

The  branches  given  off  by  the  vertebral  arteries  be- 
fore their  junction  to  form  the  basilar  artery,  are  the 
following : 

Lateral  Spinal.  Posterior  Meningeal. 

Muscular.  Anterior  Spinal. 

Anastomotic.  Posterior  Spinal. 

Inferior  Cerebellar. 


BRANCHES  OF  THE  VERTEBRAL.  169 

The  Lateral  Spinal  arteries  are  given  oif  from  the 
artery  as  it  is  passing  through  the  foramina  in  the 
transverse  processes;  they  pass  in  along  the  spinal 
nerves  to  the  interior  of  the  spinal  canal,  and  are  dis- 
tributed to  these  nerves,  to  the  medulla  spinalis  and  its 
membranes,  and  to  the  back  part  of  the  bodies  of  the 
cervical  vertebrae:  they  anastomose  with  the  other 
spinal  arteries  in  the  interior  of  the  canal. 

The  Muscular  arteries  are  given  off  from  the  vertebral 
in  its  second  and  third  stages :  these  supply  the  deep 
muscles  of  the  neck  and  anastomose  with  the  cervicalis 
superficialis  and  ascendens  colli  arteries. 

The  Anastomotic  branches  are  comparatively  large :  they 
come  off  from  the  vertebral  in  its  third  stage,  pass  back- 
wards and  outwards  and  anastomose  with  branches 
from  the  occipital  in  its  second  stage. 

The  Posterior  meningeal  artery,  described  by  Haller 
and  Soemmering,  arises  from  the  vertebral  artery,  gene- 
rally speaking,  in  the  third  stage,  passes  through  the 
occipital  foramen,  and  is  distributed  to  the  dura  mater 
lining  the  inferior  occipital  fossae,  and  to  the  fiilx  cere- 
belli :  there  may  be  two  of  these  arteries  present.  The 
branch  described  by  Soemmering  enters  the  cranium 
along  with  the  sub-occipital  nerve. 

The  Anterior  spinal  artery  arises  from  the  vertebral 
near  its  termination ;  sometimes  from  the  inferior 
artery  of  the  cerebellum,  or  even  from  the  basilar 
trunk.  It  descends  in  a  tortuous  manner,  and  unites 
with  its  fellow  from  the  opposite  side  at  the  anterior 
margin  of  the  foramen  magnum,  at  the  lower  extre- 
mity of  the  medulla  oblongata,  so  as  to  form  a  single 
trunk  larger  than  either  of  the  posterior  spinal  arte- 
ries: this  common  trunk  descends  tortuously  in  front 
of  the  spinal  marrow,  below  which  it  is  prolonged, 
without  subdividing,  through  the  centre  of  the  cauda 

15 


170  BRANCHES   OF   THE    VERTEBRAL. 

equina,  till  it  reaches  the  sacro-coccygeal  articulation, 
and  here  it  terminates  in  anastomosing  with  the  sacral 
arteries.  In  this  course  it  gives  off  branches  which 
anastomose  with  the  lateral  spinal  branches  of  the 
vertebral,  ascendens  colli,  and  cervicalis  profunda  arte- 
ries which  pass  through  the  spinal  foramina  j  and  with 
minute  branches  given  off  from  the  artery  of  the  oppo- 
site side :  this  artery  sends  many  branches  to  the  pia 
mater,  and  some  very  delicate  branches  to  the  spinal 
marrow.  It  may  be  observed  that  as  the  vertebral 
arteries  converge  superiorly  to  form  the  basilar  trunk, 
and  the  anterior  spinal  arteries  converge  inferiorly  to 
form  a  common  trunk,  the  four  arteries  necessarily 
include  a  lozenge-shaped  space  in  front  of  the  medulla 
oblongata. 

The  Fosterior  spinal  artery  inclines  downwards  and 
inwards  to  get  behind  the  spinal  marrow,  and  descends 
parallel  to  its  fellow  of  the  opposite  side,  as  far  as  the 
second  lumbar  vertebra.  In  this  course  it  gives  off 
branches  analogous  to  those  of  the  anterior  sj)inal, 
anastomoses  with  the  lateral  spinal  branches  of  the 
vertebral  and  ascendens  colli,  which  pass  through  the 
spinal  foramina,  and  with  the  minute  branches  given 
off  from  the  artery  of  the  opposite  side  :  this  artery 
sends  many  branches  to  the  pia  mater,  and  some  deli- 
cate capillary  branches  to  the  spinal  marrow :  it  is 
sometimes  a  branch  of  the  inferior  artery  of  the  cere- 
bellum. 

The  Inferior  artery  of  the  cerebellum  generally  comes, 
on  one  side  from  the  vertebral  artery,  and  on  the  other 
from  the  basilar  trunk :  both,  however,  though  rarely, 
may  come  from  the  vertebral,  or,  still  more  rarely,  both 
may  arise  from  the  basilar.  This  artery  after  its  origin 
takes  a  direction  outwards,  crossing  in  front  of  the 
pyramidal  body  when  it  arises  from  the  vertebral,  or 


BASILAR   ARTERY.  171 

either  above  or  below  the  sixth  nerve,  when  it  arises 
from  the  basilar  :  it  then  passes  backwards  between 
the  pneumogastric  and  spinal  accessory  nerves,  and 
arrives  at  the  inferior  surface  of  the  cerebellum.  Its 
first  branches,  which  are  very  small,  are  distributed  to 
the  superior  extremity  of  the  spinal  marrow,  the  origins 
of  the  eighth  and  ninth  nerves,  the  fourth  ventricle,  and 
to  the  inferior  surface  of  the  cerebellum ;  the  termina- 
ting branches,  which  are  more  considerable,  creep  along 
the  inferior  surface  of  each  hemisj^here  to  its  circum- 
ference, where  they  communicate  with  the  superior 
artery  of  the  cerebellum. 

The  Basilar  Artery,  formed  by  the  union  of  the 
two  vertebral  arteries,  proceeds  from  behind  forwards 
on  the  middle  line,  between  the  nerves  of  the  sixth  pair, 
one  of  which  lies  on  each  side,  having  the  cuneiform 
process  of  the  occipital  bone  beneath  it,  and  the  pons 
Varolii  or  great  commissure  of  the  cerebellum  above  it. 
In  this  course  it  gives  off  the  following  branches: — 

Transverse.  Superior  Cerebellar. 

Anterior  Cerebellar.  Posterior  Cerebral. 

The  Trajisverse  branches  are  few  in  number  and  small : 
they  are  distributed  to  the  pons,  and  to  the  auditory 
nerve. 

The  Aiiterior  cerebellar  branch  is  small :  it  runs  across 
the  under  surface  of  the  anterior  lobes  of  the  cerebellum, 
and  across  the  crus  cerebelli,  and  is  distributed  chiefly 
to  these  parts. 

At  the  anterior  margin  of  the  pons  the  basilar  appears 
to  terminate  by  dividing  into  four  branches,  two  for 
each  side,  viz.,  the  superior  artery  of  the  cerebellum  and 
the  posterior  artery  of  the  cerebrum. 

The  Superior   artery  of  the  cerebellum  arises  at  the 


172  POSTERIOR   ARTERY    OF    THE    CEREBRUM. 

anterior  margin  of  the  pons,  winds  round  the  crus 
cerebri,  accompanying  the  posterior  artery  of  the  cere- 
brum, from  which  it  is  separated,  first  by  the  third 
nerve,  next  by  the  fourth;  and  lastly,  by  the  tentorium. 
Having  reached  the  superior  surface  of  the  cerebellum, 
it  divides  into  a  great  number  of  branches,  some  of 
which  pass  over  the  tentorium  to  the  inferior  surface 
of  the  brain;  but  the  greater  number  pass  under  the 
tentorium  to  the  superior  surface  of  the  cerebellum, 
where,  after  minutely  subdividing,  they  are  distributed 
to  the  pia  mater,  and  anastomose  with  the  branches  of 
the  inferior  artery  of  the  cerebellum.  In  this  course  it 
supplies  the  pons  Varolii,  crus  cerebri,  tubercula  quadri- 
gemina,  pineal  gland,  velum  interpositum,  choroid 
plexus,  and  the  valve  of  Yieussens :  one  branch  of  it 
may  be  observed  to  enter  the  internal  auditory  fora- 
men, separating  the  facial  from  the  auditory  nerve. 

The  Posterior  artery  of  the  cerebrum  is  much  larger  than 
the  superior  artery  of  the  cerebellum :  at  its  origin  the 
third  nerve  hooks  round  it.  It  first  proceeds  forwards 
and  outwards,  then  turns  backwards  and  upwards,  so 
as  to  wind  round  the  crus  cerebri:  finally,  it  passes 
above  the  tentorium  to  arrive  at  the  inferior  surface  of 
the  posterior  lobe  of  the  cerebrum,  to  which  it  sends 
numerous  branches  which  first  ramify  in  the  pia  mater 
and  afterwards  penetrate  the  substance  of  the  brain: 
immediately  after  its  origin  it  gives  off  several  small 
twigs,  some  of  which  pass  through  the  locus  perforatus 
into  the  third  ventricle,  while  others  are  distributed  on 
the  crura  cerebri,  corpora  albicantia,  and  tuber  cinereum. 
"Where  it  begins  to  curve  backwards  it  receives  the 
posterior  communicating  branch  of  the  internal  carotid; 
immediately  afterwards  it  gives  off  a  choroid  branchy 
which  curves  round  the  crus  cerebelli,  and  supplies  the 
choroid  plexus,  velum  interpositum,  and  tubercula  quad- 


CIRCLE    OF   WILLIS. 


173 


rigemina.     Lastly,  it  gives   off  a  small   but  constant 
branch  that  supplies  the  fascia  dentata. 

We  may  now  review  the  arteries  which  form  what  is 
called  the  Circle  of  Willis : — in  front  we  have  the  anterior 
communicating  artery;  posterior  and  external  to  this, 

Fig.  21.— Arteries  at  the  base  of  the  Brain,  Circle  of  Willis. 


1, 1,  Posterior  Lobes  of  the  Brain.  2,  2,  Hemispheres  of  the  Cerebellum.  3,  3,  Floeculi  or  Pneu- 
mogastric  Lobes.  4,  4,  Lower  surface  of  the  Anterior  Lobe  of  the  Cerebellum.  5,  5.  Trifacial  or  fifth 
pair  of  Nerves.  6,  6,  Sixth  pair  of  Nerves.  7,  Portio  Dura  of  the  seventh  pair.  8,  Auditory  Nerve 
or  Portio  Mollis  of  the  seventh  pair.  9. 9,  Third  pair  of  nerves.  10,  10,  Crura  Cerebri.  11,  11,  Optic 
Nerves  and  Commissure.  12,  Tuber  Cinereum,  Infuudibulum,  and  Corpora  Mammillaria.  13,  13, 
The  Olfactory  Lobes.  14,  U,  Anterior  Cerebral  Lobes.  15,  15,  The  Middle  Lobes  of  the  Brain,  a,  a. 
Vertebral  Arteries,  b,  b,  Anterior  Spinal  Arteries  before  their  union,  c,  c.  Inferior  Arteries  of 
the  Cerebellum,  at  one  side  arising  from  the  Basilar  trunk,  at  the  opposite  side  from  the  Vertebral, 
d,  d,  Basilar  Arterv.  e,  e,  Anterior  Arteries  of  the  Cei-ebelluni.  f,  f,  Superior  Arteries  of  the  Cere- 
bellum, p,  g.  Posterior  Arteries  of  the  Cerebrum,  h,  h,  Posterior  Communicating  Arteries  from  the 
Internal  Carotid,  i,  i,  Internal  Carotid  Arteries,  k,  k,  Anterior  Cerebral  Arteries  connected  bj'  the 
Anterior  communicating  branch,  on  which  is  situated  the  Ganglion  of  Ribes.  1,  Anterior  communi- 
cating Artery. 


the  anterior  arteries  of  the  cerebrum,  then  the  trunks 
of  the  internal  carotids;  behind  these  the  posterior 
communicating  arteries;  next  the  posterior  arteries  of 
the  cerebrum;  and  most  posteriorly  the  anterior  termi- 
nation of  the  basilar  artery  itself:  it  is,  in  fact,  more  a 

15* 


174  INTERNAL    MAMMARY   ARTERY. 

heptagon  than  a  circle.  Within  the  circle  of  Willis  the 
following  parts  are  embraced,  viz.,  anteriorly  the  com- 
missure of  the  optic  nerves,  and  lamina  cinerea;  behind 
this  the  tuber  cinereum  and  base  of  the  infundibulum,  then 
the  corpora  mammillaria,  middle  locus  perforatus,  and 
generally,  though  situated  above  the  area  of  the  circle, 
some  of  the  filaments  of  the  origin  of  the  third  pair  of 
nerves. 

It  may  be  remarked  that  where  the  vertebral  artery 
ascends  through  vertebrae  which  have  but  little  mo- 
tion between  each  other,  it  is  not  tortuous;  but  in  the 
superior  part  of  the  neck  it  makes  a  double  curve, — first 
between  the  axis  and  atlas,  and  then  between  the  atlas 
and  occipital  bone,  in  order  as  it  were  to  escape  injury; 
for  in  this  manner,  in  passing  from  one  of  these  bones 
to  the  other,  it  traverses  twice  the  length  of  their  ver- 
tical distance  from  each  other;  so  that,  as  Mr.  Mayo 
observes,  the  artery  is  only  unbent,  not  stretched,  in 
the  more  extensive  motions  of  these  bones.  The  verte- 
bral artery  has  been  known  to  be  torn  in  fractures 
through  the  base  of  the  skull. 

The  next  branches  of  the  subclavian  artery  are  the 
internal  mammary  and  thyroid  axis,  both  of  which  arise 
opposite  the  internal  margin  of  the  scalenus  anticus 
muscle,  the  former  from  the  lower,  and  the  latter  from 
the  upper  and  anterior  surface  of  the  artery. 

The  Internal  Mammary  Artery. — In  order  to  ex- 
pose the  trunk  of  this  artery,  it  is  only  necessary  to  cut 
through  and  remove  the  costal  cartilages  and  intercostal 
muscles  which  cover  it,  and  to  saw  through  the  clavicle 
or  disarticulate  it  from  the  sternum  :  it  is  then  easy  to 
follow  its  external  and  terminating  branches,  and  the 
internal  may  be  examined  after  opening  the  thorax. 

This  vessel  arises  from  the  subclavian  opposite  to  the 


BRANCHES   OF   INTERNAL   MAMMARY.  175 

origin  of  the  thyroid  axis,  and  therefore  close  to  the  in- 
ternal margin  of  the  scalenus  anticus  muscle.  It  descends 
obliquely  forwards  and  inwards,  lying  near  the  inner  mar- 
gin of  the  scalenus  anticus  muscle,  covered  by  the  vena 
innominata  and  sterno-cleido-mastoid  muscle,  and  nearly 
parallel  to  the  phrenic  nerve  which,  in  the  first  instance, 
lies  close  to  its  outer  side.  It  then  descends  into  the 
thorax  between  the  pleura  and  costal  cartilages,  being 
sejiarated  from  the  latter  by  the  phrenic  nerve  crossing 
in  front  of  it  from  without  inwards.  Lower  down  the 
internal  mammary  artery  descends  between  the  tri- 
angularis sterni  muscle,  which  separates  it  from  the 
pleura,  and  the  costal  cartilages  and  internal  intercostal 
muscles,  which  lie  in  front  of  it.  Having  arrived  at  the 
cartilage  of  the  seventh  rib,  it  terminates  by  dividing 
into  an  internal  and  external  branch.  In  this  course  it 
is  about  a  finger's  breadth  distant  from  the  sternum. 
From  its  origin  to  the  cartilage  of  the  third  rib  it  is  in- 
clined inwards,  but  in  the  rest  of  its  course  its  direction 
is  outwards.  Its  branches  are  classed  into  the  follow- 
ing :— 

Internal.  External. 

Thymic.  Anterior  Intercostal. 
Glandular. 

Muscular.  Terminating. 

Mediastinal.  Musculo-phrenic. 

Comes  Nervi  Phrenici.  Abdominal. 

The  Internal  branches  are  distributed,  as  their  names 
imply,  to  the  thymus  gland,  to  the  adjacent  lymphatic 
glands,  to  the  sterno-hyoid  and  sterno-thyroid  muscles, 
and  to  the  areolar  tissue  of  the  anterior  mediastinum 
and  pericardium.  The  anterior  mediastinal  artery  is 
occasionally  a  direct  branch  from  the  arch  of  the  aorta. 
A  remarkable  and  constant  internal  branch,  termed  the 


176  BRANCHES   OF   INTERNAL    MAMMARY. 

comes  nervi  j^hi^enici,  accompanies  the  phrenic  nerve  in  a 
tortuous  manner,  giving  branches  as  it  descends  to  the 
thymus  gland  and  mediastinum,  to  the  pericardium, 
pulmonary  veins,  and  internal  surface  of  the  lung;  after 
which  its  terminating  branches  are  lost  in  supplying  the 
diaphragm  and  in  anastomosing  with  the  subphrenic 
branches  of  the  abdominal  aorta. 

The  External  branches,  called  also  the  anterior  inter- 
costal, correspond  to  the  intercostal  spaces,  each  of  which 
receives  one,  or,  in  some  cases,  two  arteries :  they  will 
be  found  larger  and  longer  as  we  examine  them  from 
above  downwards.  When  there  is  one  for  each  sj^ace, 
it  proceeds  along  the  inferior  margin  of  the  correspond- 
ing rib :  if  there  be  two,  one  passes  through  the  upper 
and  the  other  through  the  lower  part  of  the  intercostal 
space.  In  all  cases  they  supply  the  intercostal  muscles, 
and  communicate  with  the  terminating  branches  of  the 
superior  intercostal  artery  and  with  t*he  proper  inter- 
costal arteries  from  the  thoracic  aorta :  some  of  them 
pierce  these  muscles,  and  supply  the  pectoral  muscles, 
the  mammary  gland,  and  the  integuments. 

The  Terminating  branches  are  two  in  number;  viz.,  an 
external  and  internal.  The  external  or  musculo-phrenic 
branch  descends  obliquely  outwards,  behind  the  inferior 
costal  cartilages,  and,  having  passed  through  the  dia- 
phragm, into  which  it  sends  some  branches,  it  termi- 
nates in  supplying  the  transverse  and  oblique  muscles 
of  the  abdomen,  and  in  communicating  with  the  cir- 
cumflexae  ilii,  lumbar,  and  inferior  intercostal  arteries. 
The  inteimal  termmnimg  branch,  called  also  the  abdominal 
branch,  communicates  with  that  of  the  opposite  side  at 
the  ensiform  cartilage  of  the  sternum,  and  then  descends 
between  the  posterior  surface  of  the  rectus  muscle  and 
its  sheath.  After  sending  some  branches  to  this  muscle, 
and  others  that  pierce  its  sheath  to  arrive  at  the  broad 


THYROID   AXIS. 


177 


muscles  of  the  abdomen,  it  divides  near  the  umbilicus 
into  several  branches  which  anastomose  with  the  epi- 
gastric artery.  This  anastomosis  was  at  one  time  sup- 
posed to  be  the  cause  of  the  sympathy  between  the 
mammary  gland  and  the  uterus. 

Fig.  22.— Part  of  the  course  of  the  Internal  Mammary  and  the  Superior  Intercostal 
Arteries. 


1,  Seventh  Cervical  Vertebra.  2,  3.  4,  5.  6,  The  Upper  Dnrsal  Vertebrae.  7,  First  Rib.  8,  Second 
Rib.  9,  Third  Rib.  10,  Fourth  Rib.  11,  Twig  from  Superior  Branch  of  Intercostal  Artery.  12,  Anas- 
tomoses between  the  Anterior  Intercostal  from  the  Internal  Mammary  and  the  Superior  Intercostal 
Artery  :  Internal  Intercostal  Muscles  removed.  13.  Third  Rib.  14,  14,  14,  Sternum,  with  the  Anas- 
tomoses between  the  Mediastinal  Branches  of  the  Internal  Mammary  Artery.  15,  Clavicle.  16,  17, 
18,  Costal  Cartilages.  A,  Subclavian  Artery.  K,  First  Inferior  or  Aortic  Intercostal  Arterj-.  P,  Se- 
cond Anterior  Intercostal  Artery  from  Internal  Mammary,  b.  Vertebral  Arteiy.  c,  A  common  trunk 
which  in  this  case  gave  origin  to  the  Cervicalis  Profunda  and  Superior  Intercostal  Arteries,  d,  Cer- 
vicalis  Profunda  Artery,  e.  Superior  Intercost.il  Artery,  f,  «,  Intercostal  Arteries  from  tbe  Superior 
Intercostal,  h,  h,  Dorsal  Branches  of  Superior  Intercostal  Artery,  i,  Anastomosis  between  first 
Aortic , Intercostal  and  second  Intercostal  Branch  of  Superior  Intercostal.  1,  Superior  Branch  of 
Aortic  Intercostal,  m.  Second  Aortic  Intercostal  Artery,  n.  Internal  Mammary  Artery,  o.  First 
Intercostal  Branch  of  Internal  Mammary  Artery,  q,  q.  Internal  Branches  of  Internal"  Mammary 
Artery. 


The  Thyroii>  Axis. — This  short  trunk  arises  from  the 
subclavian  artery,  close  to  the  internal  margin  of  the 
scalenus  anticus  muscle,  and  opposite  to  the  origin  of 


178  INFERIOR   THYROID   ARTERY. 

the  internal  mammary  artery.     Immediately  after  its 
origin  it  divides  into  the  following  branches : — 

Inferior  Thyroid.  Posterior  Scapular,  or 

Supra-Scapular,  or  Trans-  Tr^nsversalis  Colli, 

versalis  Humeri. 

The  Inferior  thyroid  artery  first  ascends  a  little,  and 
then  turns  inwards  behind  the  internal  jugular  vein, 
pneumogastric  nerve,  and  carotid  artery;  towards  all 
of  which  parts  it  presents  a  slight  concavity;  its  con- 
vexity being  turned  backwards  towards  the  vertebral 
artery,  which  it  consequently  separates  from  the  carotid. 
The  trunk  of  the  sympathetic  nerve  usually  descends 
on  the  front  of  this  vessel,  forming  on  the  right  side  a 
small  ganglion,  the  middle  cervical^  which  lies  on  the 
anterior  surface  of  the  artery :  in  other,  but  rare  cases, 
the  sympathetic  nerve  descends  behind  it.  As  the  in- 
ferior thyroid  artery  approaches  the  thyroid  gland,  it 
forms  another  slight  curve,  the  concavity  of  which  looks 
backwards  and  corresponds  to  the  recurrent  nerve,  which 
a  little  farther  on  passes  between  its  terminating  branches, 
particularly  on  the  right  side  :  on  the  left  side  we  find 
that,  in  addition  to  the  preceding  relations,  the  inferior 
thyroid  artery  lies  on  the  oesophagus,  and  is  intimately 
connected  with  the  thoracic  duct,  which  usually  lies 
behind  it  in  the  first  instance,  and  then  makes  an  arch 
to  terminate  in  the  left  subclavian  vein  in  front  of  the 
artery.  The  branches  of  the  inferior  thyroid  artery 
are  classed  into  the  inferior,  superior,  and  terminating. 
The  Inferior  branches  are  variable  in  number;  they  de- 
scend into  the  chest,  supply  the  oesophagus,  longus  colli 
muscle,  bronchial  tubes  and  glands,  and  anastomose 
with  the  superior  intercostal  and  bronchial  arteries. 
The  Superior  branches  are  distributed  to  the  longus  colli 
and  anterior  scalenus  muscles :  one  of  these  is  constant, 


SUPRA-SCAPULAR   ARTERY.  179 

and,  though  usually  smallj  is  sometimes  of  considerable 
size;  it  is  termed  the  ascendens  colli;  it  ascends  on  the 
front  of  the  scalenus  anticus  muscle,  parallel  and  inter- 
nal to  the  phrenic  nerve.  Its  branches  are  distributed 
to  the  muscles  on  the  front  of  the  vertebral  column ; 
some  of  them  inosculate  with  descending  branches  of 
the  occipital  artery,  and.  others  penetrate  the  lateral 
foramina  of  the  spine  to  communicate  with  branches 
of  the  vertebral.  The  ascendens  colli  often  comes  off 
directly  from  the  thyroid  axis,  and  is  frequently  so 
described.  The  Terminating  branches  of  the  inferior 
thyroid  artery  enter  into  the  inferior  and  posterior  por- 
tion of  the  thyroid  gland,  anastomose  with  the  termi- 
nating branches  of  the  superior  thyroid,  and  are  lost  in 
the  substance  of  the  gland. 

The  operation  of  tying  one  or  more  of  the  thyroid 
arteries  has  been  performed  with  a  view  to  diminish  the 
size  of  a  bronchocele,  or  previously  to  extirpation  of  the 
thyroid  gland.  The  inferior  thyroid  artery  may  be  ex- 
posed by  laying  bare  the  sheath  of  the  carotid  artery  in 
the  manner  already  recommended,  and  drawing  it  to  the 
external  side:  when  this  has  been  done,  the  inferior 
thyroid  artery  may  be  discovered  crossing  inwards, 
opposite,  in  most  cases,  to  the  fifth  cervical  vertebra; 
and  care  will  be  necessary  to  avoid  the  recurrent  and 
sympathetic  nerves  on  both  sides,  and  the  thoracic  duct 
on  the  left  side. 

The  inferior  thyroid  artery  of  the  left  side  is  particu- 
larly engaged  in  performing  the  operation  of  cesopha- 
gotomy. 

The  Supra-scapular  J  or  transversalis  humeri  artery,  runs 
horizontally  outwards,  in  front  of  the  anterior  scalenus 
muscle,  the  phrenic  nerve,  the  brachial  plexus,  and  the 
posterior  scalenus  muscle,  being  covered  anteriorly  by 
the   clavicle    and    the    sterno-mastoid    and    trapezius 


180  POSTERIOR   SCAPULAR   ARTERY. 

muscles.  In  this  course  it  gives  off  a  thoracic  and  acro- 
mial branch;  and  then  passes  over  the  ligament  of  the 
notch  in  the  superior  margin  of  the  scapula,  placed  be- 
tween the  origin  of  the  omo-hyoid  muscle  and  the  apex 
of  the  conoid  ligament :  from  this  it  dips  into  the  supra- 
spinata  fossa,  where  it  terminates  by  dividing  into  the 
supra-spinata  and  infra-spinata  arteries.  The  nerve  cor- 
responding to  the  supra-scapular  artery  usually  passes 
under  the  ligament  of  the  notch.  Sometimes,  however, 
though  rarely,  we  find  their  position  reversed,  the  artery 
passing  beneath  and  the  nerve  above  the  ligament,  or 
both  may  go  together  beneath  it.  The  thoracic  branch 
is  small;  it  descends  through  the  substance  of  the  subcla- 
vian muscle,  to  communicate  with  the  thoracic  branches 
of  the  axillary  artery.  The  acromial  branch  is  consider- 
able; it  usually  arises  from  the  supra-scapular,  as  it  is 
passing  into  the  supra-spinata  fossa,  but  may  arise  from 
it  in  any  2)art  of  its  course ;  it  supplies  the  trapezius  and 
supra-spinatus  muscles,  and  the  periosteum  and  integu- 
ments covering  the  acromion  process.  The  supra-spinata 
artery  is  entirely  lost  in  the  muscle  of  the  same  name. 
The  infra-spinata  artery  descends  in  front  of  the  spine  of 
the  scapula  and  beneath  the  spino-glenoid  ligament  of 
Sir  A.  Cooper :  having  arrived  in  the  infra-spinata  fossa, 
it  gives  off  several  branches  to  the  muscles  of  this  region, 
and  then  forms  a  curve  to  anastomose  with  the  posterior 
branch  of  the  sub-scapular  artery :  it  also  sends  a  deli- 
cate branch  along  the  axillary  margin  of  the  scapula, 
towards  its  inferior  angle,  where  it  anastomoses  with 
the  posterior  scapular  artery. 

The  Posterior  scapular^  or  transversalis  colli  artery^ 
larger  than  the  supra-scapular,  passes  horizontally  out- 
wards in  front  of  the  anterior  scalenus  muscle  and  phre- 
nic nerve ;  afterwards,  in  front  of  the  upper  part  of  the 
brachial  plexus  and  posterior  scalenus  muscle,  in  order 


CERVICALIS    PROFUNDA    ARTERY.  181 

to  arrive  at  the  superior  angle  of  the  scapula.  In  this 
course  it  is  covered  by  the  sterno-mastoid  and  trapezius 
muscles :  under  cover  of  this  last  muscle  it  gives  off  the 
cervicalis  superjicialis,  which  ascends  on  the  side  and  back 
of  the  neck,  supplies  the  splenius  and  trapezius  muscles, 
the  integuments  and  lymphatic  glands,  and  anastomoses 
with  the  descending  cervical  branches  of  the  occipital 
artery.  Having  arrived  at  the  superior  angle  of  the 
scapula,  the  posterior  scapular  artery  gets  under  cover 
of  the  levator  anguli  scapulas  muscle,  to  which  it  sends  a 
few  small  vessels,  and  divides  into  two  branches  of  nearly 
equal  size;  07ie  of  which,  the  posterior  scapular  branchy 
properly  so  called,  descends  along  the  vertebral  margin 
of  the  scapula,  covered  by  the  rhomboid  muscles  and 
levator  anguli  scapulae,  to  each  of  which,  and  to  the 
serrati  and  latissimus  dorsi,  it  sends  a  supply  of  blood. 
The  other  branch  descends  more  internally,  being  covered 
by  the  scapula,  and  supplies  the  sub-scapular  and  serra- 
tus  major  anticus  muscles.  We  will  occasionally  find 
the  posterior  scapular  branch  of  this  artery  arising  from 
the  subclavian  artery  at  the  commencement  of  its  third 
stage,  passing  through  the  brachial  plexus  of  nerves,  and 
thus  arriving  at  its  destination :  in  this  case  the  cervi- 
calis superficialis  will  form  a  distinct  branch  of  the  thy- 
roid axis. 

In  the  second  part  of  its  course,  while  under  cover  of 
the  scalenus  anticus  muscle,  the  subclavian  artery  gives 
off  the  cervicalis  profunda  and  superior  intercostal  arte- 
ries, which  frequently  arise  from  it  by  a  common  trunk. 

The  Cervicalis  Profunda  Artery  is  a  small  but  con- 
stant branch  which  passes  backwards  through  the  bra- 
chial plexus,  and  between  the  transverse  process  of  the 
seventh  cervical  vertebra  and  the  first  rib:*  it  is  situated 


*  When  there  is  a  cervical  rib,  it  passes  between  this  rib  and  the  first 

dorsal. 

16 


182         SUPERIOR  INTERCOSTAL  ARTERY. 

underneath  the  last  cervical  nerve,  and  separates  this 
nerve  from  the  neck  of  the  first  rib.  It  then  ascends  on 
the  back  of  the  neck,  in  the  groove  between  the  spinous 
and  transverse  process  of  the  cervical  vertebrae,  lying 
on  the  spino-transverse  muscle  and  covered  by  the  great 
complexus.  It  supplies  the  deep-seated  muscles  on  the 
back  of  the  neck,  and  anastomoses  with  the  vertebral 
and  descending  cervical  of  the  occipital  arteries. 

The  Superior  Intercostal  Artery  inclines  a  little 
backwards,  arches  over  the  top  of  the  lung  and  pleura, 
and  descends  into  the  thorax,  having  behind  it  the  neck 
of  the  first  rib,  and  the  first  dorsal  nerve,  as  the  latter 
ascends  from  the  thorax.  In  front  it  is  covered  by  the 
pleura,  and  on  the  inside  it  is  separated  from  the  margin 
of  the  longus  colli  muscle  by  the  first  thoracic  ganglion 
of  the  sympathetic  nerve.  These  parts  will  therefore 
lie  in  the  following  order,  commencing  at  the  bodies  of 
the  vertebrae  and  passing  outwards: — first,  the  longus 
colli  muscle;  secondly,  the  first  thoracic  ganglion  of  the 
sympathetic;  thirdly,  the  superior  intercostal  artery; 
and  fourthly,  the  first  dorsal  nerve  as  it  passes  obliquely 
across  the  neck  of  the  first  rib  to  unite  with  the  last 
cervical.  The  artery  then,  in  many,  if  not  in  most  cases, 
goes  out  of  the  thorax,  passing  between  the  first  and 
second  ribs,  and  re-enters  between  the  second  and  third. 
This  artery  gives  off  the  intercostals  of  the  first  and 
second,  and  sometimes  of  the  third,  or  more  intercostal 
spaces ;  these  anastomose  with  branches  of  the  anterior 
intercostals  from  the  internal  mammary  artery;  a  small 
descending  branch  communicates  with  the  first  aortic 
intercostal. 

The  superior  intercostal  artery  is  always  small,  and 
sometimes  deficient. 


AXILLA.  183 

AXILLA. 

This  region  has  the  form  of  a  three-sided  pyramid. 
The  apex  is  truncated  and  directed  upwards  and  inwards, 
and  is  bounded  posteriorly  by  the  superior  margin  of  the 
scapula,  anteriorly  by  the  clavicle,  and  internally  by  the 
first  rib :  through  this  truncated  apex  the  region  of 
the  axilla  communicates  freely  with  the  supra-clavicular 
region  of  the  neck.  The  hase^  directed  downwards  and 
outwards,  presents  the  excavation  termed  the  arm-pit  j 
by  abducting  the  arm,  the  concavity  of  the  surface  may 
be  diminished,  but  certainly  cannot  be  rendered  convex, 
as  some  writers  represent.  The  anterior  wall  is  formed 
by  the  greater  and  lesser  pectoral  muscles;  the  postero- 
external wall  by  the  sub-scapular,  the  teres  major,  and 
latissimus  dorsi  muscles;  and  the  internal  wall,  w^hich  is 
convex  externally,  is  formed  by  the  ribs,  intercostal 
muscles,  and  serratus  major  anticus.  The  anterior  and 
posterior  walls  are  united  by  a  strong  fascia,  which  con- 
tributes to  form  the  base  of  this  cavity,  and  may  be  ex- 
posed by  raising  the  integuments  :  externally,  this  fascia 
is  continuous  with  the  aponeurosis  covering  the  inside 
of  the  arm;  and  internally,  it  is  lost  on  the  muscles  of 
the  thorax.  We  usually  find  the  fascia  at  the  base  of 
this  region  strengthened  by  firm  narrow  tendinous  bands 
passing  from  the  anterior  to  the  posterior  fold  of  the 
axilla ;  and  occasionally  there  may  be  observed  muscular 
bands  taking  the  same  direction ;  several  authors  have 
described  them,  particularly  Mr.  Lucas,  in  his  paper  on 
the  "  Anomalies  of  the  muscular  system."*  The  student 
may  now  abduct  the  arm,  and  remove  these  structures, 
in  order  to  examine  the  contents  of  the  axilla.  The 
muscles  and  the  great  axillary  vessels  and  nerves  descend 
externally  along  the  humerus,  the  vein  being  most  super- 

*  Lancet,  September  22,  1838. 


184  AXILLA. 

• 

ficial:  a  large  artery,  the  thoracica  longa,  may  be  felt 
descending  behind  the  lower  margin  of  the  pectoralis 
major ;  and  another,  the  inferior  or  subscapular,  along  the 
lower  margin  of  the  sub-scapularis  muscle.  When  the 
arm  is  very  much  abducted,  this  last-mentioned  artery 
has  its  direction  altered  so  as  to  make  it  nearly  parallel 
with  the  axillary  artery,  for  which  it  may  possibly  be 
mistaken.  From  this  account  it  is  evident  that,  if  we 
proceed  to  extirpate  diseased  glands  from  the  axilla,  we 
should  cut  towards  the  thorax ;  as  in  every  other  direc- 
tion we  encounter  important  vessels. 

The  Lymphatic  glands  found  in  the  axilla  are  classed 
into  two  sets ;  a  superficial  set,  which  are  found  along 
the  inferior  margins  of  the  axillary  folds  j  and  a  deeper 
set,  which  accompany  the  great  vessels.  In  the  advanced 
stages  of  cancer,  we  find  these  glands  enlarged  and  hard- 
ened, as  also  those  along  the  outer  edge  of  the  sternum, 
and  above  the  clavicle. 

After  having  raised  the  integuments  from  off  the  an- 
terior wall  of  this  region,  w^e  will  observe  some  scattered 
fibres  of  the  origin  of  the  platysma  myoides  together 
with  the  supra-clavicular  branches  of  the  cervical  plexus 
of  nerves  situated  underneath.  Having  cleanly  re- 
moved these  parts,  the  great  j)ectoral  muscle  becomes 
exposed:  it  has  three  sets  of  origins, — one  from  the 
clavicle,  the  second  from  the  sternum,  and  the  third 
from  the  ribs;  these  are  separated  by  areolar  intervals. 
It  is  into  that  interval  which  separates  the  clavicular 
from  the  sternal  origin  that  some  of  the  continental 
surgeons  propose  to  make  their  incision,  in  order  to  come 
dow^n  on  the  axillary  artery  in  its  first  stage.  The  outer 
edge  of  this  muscle  is  separated  from  the  deltoid  by  an- 
other areolar  interval,  triangular  in  form,  called  the  del- 
toidal  groove,  the  base  of  which  is  situated  suj^eriorly  at 
the  clavicle,  the  apex  inferiorly  at  the  insertion  of  the 


AXILLA.  185 

pectoralis  major  and  deltoid  muscles:  this  space  con- 
tains the  cephalic  vein  and  the  thoracico-humeraria 
artery.  More  externally,  but  not  forming  a  part  of  the 
anterior  wall  of  the  axilla,  we  observe  a  rounded  promi- 
nence corresponding  to  the  head  of  the  humerus,  and 
covered  by  the  anterior  or  clavicular  division  of  the  del- 
toid muscle.  A  little  internal  to  this,  and  also  covered 
by  the  deltoid  muscle,  may  be  felt  the  coracoid  process, 
between  which  and  the  head  of  the  humerus,  Lisfranc 
proposed  to  sink  the  knife,  for  the  purpose  of  amputating 
at  the  shoulder-joint. 

On  raising  the  pectoralis  major,  we  bring  into  view  the 
anterior  thoracic  nerve,  and  the  thoracica  longa  artery 
which  was  concealed  by  the  lower  border  of  the  muscle; 
also  the  pectoralis  minor,  which  becomes  narrow  as  it 
passes  upwards  and  outwards,  to  be  inserted  under  cover 
of  the  deltoid  muscle  into  the  coracoid  process  of  the 
scapula.  We 'may  observe  that  the  cephalic  vein  as- 
cends in  front  of  this  muscle,  and  the  axillary  vein  behind 
it,  and  that  the  former  empties  itself  into  the  latter 
opposite  to  its  superior  margin.  Corresponding  to  the 
upper  edge  of  this  muscle  we  also  find  the  acromial 
axis  or  artery,  which  separates  it  from  the  subclavian 
muscle  and  costo-coracoid  ligament  or  ligamentum  Ucorne. 
This  ligament  arises  by  rather  a  narrow  origin  or  cornu 
from  the  cartilage  of  the  first  rib,  and  passing  outwards 
becomes  attached  by  a  second  cornu  to  the  coracoid  pro- 
cess :  its  upper  margin  is  attached  to  the  clavicle,  and 
the  inferior,  which  is  lunated,  looks  downwards  and  in- 
wards :  in  front  it  is  covered  by  the  great  pectoral  muscle, 
and  posteriorly  it  lies  on  the  subclavius  muscle,  behind 
which  it  sends  a  delicate  production :  from  its  inferior 
or  concave  margin  an  expansion  more  or  less  strong 
descends  over  the  vessels,  and  covers  the  anterior  surface 
of  the  pectoralis  minor  muscle.     We  may  now  detach 

16* 


186  AXILLARY   ARTERY. 

the  origin  of  this  latter  muscle  from  the  thorax,  and  we 
will  observe,  on  reflecting  it  outwards,  a  small  slender 
nerve,  the  middle  thoracic,  entering  its  posterior  surface. 
The  contents  of  the  axilla  are  now  brought  fully  into 
view.  Externally  we  observe  descending  along  the 
humerus,  the  biceps  and  coraco-brachiahs  muscles;  more 
internally  the  axillary  artery,  with  its  accompanying 
vein  and  the  brachial  plexus  of  nerves.  Two  nerves  cross 
the  axilla,  from  within  outwards,  to  reach  the  arm ;  these 
are  sometimes  called  the  nerves  of  Wrisberg ;  they  are 
branches  of  the  second  and  third  intercostal  nerves,  and 
pass  from  them  through  the  corresponding  intercostal 
spaces:  the  superior  is  the  larger.  Lastly,  far  back, 
and  on  the  inner  wall  of  the  axilla,  we  observe  a  long 
thoracic  nerve,  descending  behind  the  axillary  vessels, 
on  the  axillary  or  external  surface  of  the  serratus  major 
anticus  muscle :  this  is  the  posterior  thoracic  or  exteryial 
respiratory  nerve  of  Bell.  These  parts,  in  a'ddition  to  the 
lymphatic  glands  already  noticed,  and  a  considerable 
quantity  of  areolar  tissue,  together  with  numerous 
branches  of  arteries,  veins,  and  nerves,  form  the  contents 
of  the  axilla. 

THE   AXILLARY   ARTERY. 

This  vessel  commences  at  the  lower  margin  of  the  first 
rib,  and  proceeds  obliquely,  downwards,  backwards,  and 
outw^ards,  to  terminate  opposite  the  lower  margin  of  the 
tendons  of  the  teres  major  and  latissimus  dorsi  muscles. 
In  this  course  it  is  situated  deeper  above  than  below, 
and  forms,  wdien  the  elbowMS  brought  to  the  side,  a  slight 
curvature,  the  convexity  of  which  is  turned  outwards. 
It  is  usually  described  as  having  three  stages :  in  the 
first,  it  is  above  the  pectoralis  minor;  in  the  second, 
behind  it;  and  in  the  third,  below  it. 

First  stage  of  the  Axillary  artery. — Anteriorly,  it  is 


AXILLARY   ARTERY. 


187 


covered  by  the  integuments,  the  platysma,  supra-clavicu- 
lar branches  of  the  cervical  plexus,  the  upper  portion  of 
the  pectoralis  major,  and  immediately  under  cover  of  this 
muscle,  by  some  areolar  tissue,  together  with  the  expan- 
sion of  fascia  given  off  from  the  ligamentum  bicorne ; 
and  close  to  the  clavicle  by  the  ligament  itself,  and  a 

Fig.  23.  —  Ftew  of   the  Axillary  Artery,  portions   of   the  Pectoral  and  Deltoid 
Muscles  removed. 


1,  Axillary  Artery.  2,  Superior  Thoracic.  3.  Acromial  Thoracic.  4,  Long  Thoracic.  5,  Sab- 
Bcapular.  6,  Anterior  Circumflex.  7,  Posterior  Circumflex.  8,  Brachial  Artery.  9,  Superior  Pro- 
found Artery. 

small  portion  of  the  inferior  margin  of  the  subclavius 
muscle :  we  find  also  anterior  to  the  artery  and  vein  the 
anterior  thoracic  nerve,  small  branches  of  which  curve 
underneath  the  vessel  and  unite  with  the  middle  thoracic 
nerve  which  descends  behind  it,  thus  forming  a  nervous 
loop  around  the  artery.  Posteriorly^  it  rests  against  the 
external  layer  of  the  first  intercostal  muscles,  and  cor- 
responds, with  the  interposition  of  some  areolar  tissue, 


188  AXILLARY   ARTERY. 

to  the  origin  which  the  serratus  magnus  takes  from  the 
second  rib.  BxternaUy,  it  is  related  to  the  brachial 
plexus  of  nerves ;  these  nerves  lie  also  upon  a  plane 
somewhat  above  the  level  of  the  artery;  the  trunk 
formed  by  the  union  of  the  eighth  cervical  and  first  dorsal 
nerves  lies  nearer  to  the  artery,  and  upon  a  plane  supe- 
rior, external,  and  posterior  to  this  vessel.  Internalli/, 
it  is  in  close  relation  to  the  axillary  vein,  which,  when 
distended  with  blood,  overlaps  the  inner  portion  of  the 
artery,  and  gets  more  in  front  of  it  as  it  descends.  In 
this  situation  the  vein  corresponds  to  the  two  first  ribs 
and  to  the  upper  part  of  the  serratus  magnus.  Thus  in 
the  first  stage  the  artery  lies  between  the  brachial  plexus 
on  the  outside,  and  the  axillar}'  vein  upon  the  inside. 

Second  stage  of  the  Axillary  artery. — Ajiteriorly,  in 
addition  to  the  integuments  and  pectoralis  major,  it  is 
covered  more  immediately  by  the  pectoralis  minor 
muscle,  and  about  the  middle  of  this  stage  by  a  portion 
of  the  superior  trunks  of  the  brachial  plexus  of  nerves, 
in  which  situation  the  plexus  forms  a  complete  sheath 
around  the  artery.  Posteriorly  it  corresponds  to  a 
quantity  of  areolar  tissue  lying  between  the  artery  and 
sub-scapularis  muscle.  Externally  it  is  related  to  the 
upper  part  of  the  insertion  of  the  sub-scapularis  tendon 
into  the  lesser  tuberosity  of  the  humerus,  and  partly  to 
the  brachial  plexus.  Internally  we  find  the  axillary  vein 
and  some  areolar  tissue  separating  it  from  the  serratus 
magnus. 

Third  stage  of  the  Axillary  artery. — Anteriorly y  besides 
by  the  integuments  and  pectoralis  major  muscle,  it  is 
covered  by  the  union  of  the  two  roots  of  the  median 
nerve,  and  for  a  very  short  distance  by  the  nerve  itself, 
which,  however,  inclines  towards  the  outer  side  of  the 
artery;  at  the  lower  part  of  this  stage  the  artery  is 
overlapped  by  the  belly  of  the  coraco-brachialis  muscle. 


LIGATURE    OF   THE   AXILLARY   ARTERY.  189 

Posteriorly^  it  rests  against  part  of  the  tendon  of  the 
sub-scapularis  muscle,  and  below  this  on  the  teres  major 
and  latissimus  dorsi  muscles,  where  it  loses  the  name  of 
axillary  artery.  Externally  it  is  related  to  the  lower 
part  of  the  insertion  of  the  sub-scapular  tendon,  to  the 
external  head  of  the  median  nerve,  and  to  the  external 
cutaneous  nerve.  Internally  it  corresponds  to  the  in- 
ternal head  of  the  median,  to  the  internal  cutaneous 
and  ulnar  nerves,  and  to  its  own  vein  with  the  inter- 
position of  these  nerves. 

With  regard  to  the  relations  between  the  axillaiy 
artery  in  its  three  stages,  and  the  brachial  plexus  of 
nerves,  we  may  repeat  that  in  the  first  stage  the  brachial 
plexus  is  above  and  external  to  the  artery;  in  about  the. 
middle  of  the  second  stage  the  termination  or  apex  of 
the  plexus  forms  a  complete  sheath  around  it;  and  in 
the  third  stage  it  has  the  branches  of  the  plexus 
arranged  around  it  in  the  following  order :  viz.,  in  front, 
and  crossing  slightly  to  its  outside,  is  the  median  nerve, 
and  one  or  two  slips  uniting  its  roots;  on  the  outside 
are  the  external  cutaneous  nerve  and  external  head  of 
the  median;  on  the  inside,  the  internal  head  of  the 
median,  and  the  internal  cutaneous  nerve  lying  on  the 
ulnar;  and  posteriorly,  the  musculo-spiral  and  circumflex 
nerves. 

LIGATURE   OF   THE   AXILLARY   ARTERY. 

This  artery  may  be  tied  in  its  first  and  third  stages; 
in  the  second  stage,  however,  the  operation  must  neces- 
sarily be  attended  with  considerable  difficulty,  in  conse- 
quence of  its  great  depth  from  the  surface  and  its  close 
relation  to  the  brachial  plexus  of  nerves. 

Operation  of  tying  the  Axillary  artery  in  its  first  stage. 
The  operation  is  extremely  difficult,  from  the  depth  of 
the  artery,  and  the  difficulty  of  distinguishing  it  from 


190  LIGATURE   OF   THE   AXILLARY   ARTERY. 

the  adjacent  nerves  of  the  brachial  plexus,  and  on 
account  of  the  situation  of  the  axillary  vein  and  the 
probable  occurrence  of  troublesome  venous  hemorrhage; 
for  these  reasons  the  ligature  of  the  subclavian,  in  its 
third  stage,  is  generally  preferred  for  the  cure  of  axillary 
aneurism.  The  following  mode  of  operating  is  essen- 
tially the  same  as  that  recommended  by  Mr.  Hodgson. 
The  patient  should  be  seated  in  a  reclining  chair,  or 
laid  on  a  table,  so  as  to  let  the  light  fall  on  the  site  of 
the  operation.  The  arm  being  abducted,  a  semilunar 
incision  should  be  next  made,  commencing  within  an 
inch  of  the  sternal  end  of  the  clavicle,  and  stopping 
short  externally  at  the  edge  of  the  deltoid  muscle,  in 
order  to  avoid  injuring  the  cephalic  vein.  This  incision 
will  have  its  convexity  turned  downwards,  and  will 
divide  the  integuments  and  platysma  myoides.  The 
fibres  of  the  great  pectoral  muscle  should  then  be  divided 
in  the  same  manner,  and  to  the  same  extent.  On  re- 
tracting the  lips  of  the  wound,  the  pectoralis  minor 
muscle  will  be  seen  crossing  it  inferiorly.  This  muscle 
may  now  be  relaxed,  by  bringing  the  arm  nearer  to  the 
side,  and  should  then  be  depressed  with  a  blunt  instru- 
ment, so  as  to  give  more  room  to  the  operator.  By 
cautiously  scraping  through  the  areolar  membrane,  the 
acromial  artery  will  be  found  projecting  over  the  edge 
of  the  muscle,  and  will'  assist  in  guiding  us  to  the 
axillary  artery:  the  costo-coracoid  ligament  may  be 
divided,  if  necessary,  on  a  director.  We  should  remem- 
ber that  the  anterior  thoracic  nerve  is  in  front  of  the 
artery;  the  brachial  plexus  above  and  to  the  outside 
of  it;  and  the  vein,  which  often  swells  suddenly  out  in 
front  of  the  artery  during  expiration,  is  on  a  plane 
anterior  and  internal  to  it.  Having  found  the  artery, 
the  needle  must  be  passed  round  it,  from  within  out- 
wards, in  order  to  avoid  injuring  the  vein,  which  should 


THE   AXILLARY   ARTERY. 


191 


Fig.  2L— Surgical  Anatomy  of  the  Axillary  Artery  in  part  of  its  course. 


A,  Axillary  Vein  drawn  downwards.  Tiie  Internal  Cutaneous  Nerve  crosses  the  vein,  and  one  of 
the  nerves  of  Wrisberg  is  in  immediate  relation  with  it  internally.  B,  Axillary  Artery  croised  by 
one  of  the  roots  of  Median  Nerve.  C,  Coraco-brachialis  Muscle.  D,  Biceps  Muscle.  E,  Pectoralis 
Major  Muscle.  F,  Pectoralis  Minor  Muscle.  G,  Serratus  Magnus  Muscle.  H,  An  Axillary  gland 
crossed  by  a  branch  of  the  External  Respiratory  Nerve.  I,  Infra  or  Subscapular  Artery.  K,'Latissi- 
nius  Dorsi  Muscle.  L,  Teres  Major  Muscle,  a.  Trunk  formed  by  Venae  Comites.  b,  Basilic  Vein 
assisting  in  forming  the  Axillary  Vein,    g,  Fascia. 


192  LIGATURE   OF   THE   AXILLARY   ARTERY. 

be  drawn  inwards  with  a  blunt  hook  or  a  curved  spatula. 
Before  tightening  the  ligature,  we  should  ascertain  that 
compression  of  the  included  part  restrains  the  pulsation 
of  the  aneurismal  tumor. 

Manec  recommends  the  following  method : — "  The 
patient  should  lie  with  the  shoulder  rather  elevated,  so 
that  the  artery  may  be  a  little  separated  from  the  vein; 
to  attain  this  end  the  elbow  must  be  four  or  five  inches 
apart  from  the  body :  the  surgeon  then  makes  an  incision 
two  or  three  inches  long,  its  external  extremity  com- 
mencing upon  the  internal  part  of  the  deltoid  muscle, 
and  prolonged  more  or  less  towards  the  internal  ex- 
tremity of  the  clavicle;  it  should  be  parallel  with  the 
anterior  edge  of  that  bone,  and  about  eight  lines  below 
it.  In  giving  this  direction  to  the  incision,  an  advantage 
arises  in  being  able  to  arrive  directly  upon  the  vessels 
and  nerves  from  before  backwards,  so  that  the  artery 
can  be  more  easily  insulated  ;  on  the  contrary,  when 
the  incision  is  parallel  with  the  layer  of  cellular  tissue 
separating  the  clavicular  from  the  sternal  portion  of 
the  great  pectoral,  it  is  true  its  fibres  are  not  divided, 
hut  the  wound  does  not  correspond  with  the  direction  of  the 
artery/'  The  remaining  steps  of  the  operation  consist 
in  the  transverse  division  of  the  fibres  of  the  greater 
pectoral  and  in  the  tying  of  the  artery.  Manec's  method 
is  nearly  similar  to  that  recommended  by  Mr.  Hodgson. 

To  these  methods  it  has  been  objected,  by  some  of 
the  continental  surgeons,  that  the  pectoralis  major 
muscle  is  divided  transversely  to  a  considerable  extent, 
and  the  shoulder  thereby  considerably  weakened;  they, 
therefore,  prefer  an  incision  in  the  course  of  its  fibres, 
and  separating  its  clavicular  from  its  sternal  portion. 
The  objection  to  the  transverse  division  of  the  fibres  of 
the  great  pectoral  is  more  fanciful  than  real,  whilst 
there  is  a  decided  objection  to  the  plan  of  coming  down 


LIGATURE   OP   THE   AXILLARY   ARTERY.  193 

upon  the  artery  by  cutting  between  the  clavicular  and 
sternal  origins  of  the  pectoralis  major  muscle, — viz. 
that  this  incision  will  conduct  us  more  directly  upon 
the  vein  than  upon  the  artery. 

The  operation  of  tying  the  Axillary  artery  in  its  second 
stage  has  been  recommended  by  Delpech :  he  divides 
the  pectoralis  minor  muscle  and  thus  secures  the  artery 
in  this  stage.  He  has  in  this  way  twice  taken  up  the 
artery  successfully  for  hemorrhage  after  amputation.* 

Operation  of  tying  the  Axillary  artery  in  its  third  stage. 
The  artery  may  be  reached  either  by  cutting  through 
the  anterior  wall  of  the  axilla,  or  through  its  base.  If 
we  prefer  the  former  plan,  we  make  our  incision  about 
three  inches  long,  over  the  areolar  interval  between  the 
deltoid  and  great  pectoral  muscles,  taking  care  not  to 
injure  the  cephalic  vein.  After  scraping  through  some 
areolar  tissue,  the  pectoralis  minor  muscle  is  exposed ; 
and  beneath  it  (i.e.  nearer  to  the  base  of  the  axilla)  we 
can  feel  the  common  cord  formed  by  the  vessels  and 
nerves.  The  distended  vein  is  then  drawn  inwards,  and 
the  artery  which  lies  between  the  roots  of  the  median 
nerve  must  be  insulated  carefully  and  tied. 

The  operation  through  the  base  of  the  axilla  may  be 
thus  performed  : — the  patient  being  placed  on  a  table, 
and  the  arm  abducted  and  supinated,  an  incision  about 
two  inches  and  a  half  in  length  should  be  cautiously 
made  through  the  integuments  and  fascia  of  the  axilla, 
in  the  direction  of  the  head  of  the  humerus.  The 
coraco-brachialis  muscle  will  then  form  a  good  guide  to 
the  artery :  by  carefully  scraping  through  the  areolar 
tissue,  the  axillary  vein  will  be  exposed :  the  median 
nerve  will  also  present  itself,  and  may  be  drawn  out- 
wards while  the  vein  is  pressed  inwards,  and  the  aneu- 


*  Chirurg.  Clinique,  vol.  i. 
17 


194  RUPTURE  OF  AXILLARY  ARTERY. 

rism-needle  carried  cautiously  round  the  artery  from 
within  outwards. 

The  axillary  artery  has  been  torn  both  by  the  attempts 
made  to  reduce  a  luxation  of  the  humerus,  and  by  the 
head  of  the  bone  itself  in  the  very  act  of  being  dislo- 
cated into  the  axilla :  these  occurrences  are  exceedingly 
rare.  M.  Floubert,  of  Eouen,  relates  a  case  of  the  former, 
and  the  following  very  interesting  examj^le  of  the  latter 
is  related  by  Mr.  Adams,  one  of  the  surgeons  to  the 
Eichmond  Hospital,  in  the  35th  number  of  Todd's  Cy- 
clopaedia of  Anatomy  and  Physiology.  The  laceration 
of  the  axillary  artery  was  recognized  a  few  minutes 
after  dislocation  had  occurred,  and  before  any  effort 
whatever  had  been  made  to  restore  the  humerus  to  its 
place. 

Case  of  Rupture  of  the  axillary  artery j  caused  by  luxa- 
tion of  the  head  of  the  humerus  into  the  axilla. — John 
Smith,  aged  50,  was  thrown  down  by  a  runaway  horse 
one  morning  during  the  summer  of  1833;  in  about  ten 
minutes  after  this  occurred  he  was  brought  to  Jervis 
Street  Hospital,  when  the  writer,  at  that  time  one  of  the 
surgeons  of  the  Institution,  was  j)rescribing  for  the 
extern  patients.  The  man  was  in  a  cold  perspiration, 
pallid,  and  apparently  on  the  verge  of  syncope.  The 
writer  immediately  observed  that  the  patient  had  a  dis- 
location of  his  left  humerus  into  the  axilla,  and  proceed- 
ing to  point  out,  as  was  his  custom,  to  the  chnical  class, 
the  diagnostic  marks  of  the  luxation,  he  noticed  that 
the  cavity  of  the  axilla  was  filled  up  to  a  remarkable 
degree.  This  sudden  filling  up  of  the  axilla  he  imme- 
diately concluded  could  be  attributed  to  no  other  source 
than  to  the  laceration  of  a  large  artery.  He  quickly 
sought  for  the  pulse  in  the  radial  and  brachial  artery 
of  the  dislocated  limb,  but  no  pulse  could  be  felt  in  any 
artery  below  the  site  of  the  left  subclavian,  while  the 


RUPTURE  OF  AXILLARY  ARTERY.         195 

pulse,  though  feeble,  could  be  readily  felt  at  the  heart, 
and  in  every  external  artery  of  the  system,  except  in 
those  of  the  dislocated  arm.  The  writer  then  observed 
to  the  clinical  class,  that  in  this  case  there  were  two 
lesions  to  be  noticed,  namely,  a  dislocation  into  the 
axilla,  the  features  of  w^hich  were  very  well  marked, 
complicated  with  a  rupture  of  the  axillary  artery ;  in  a 
word,  besides  the  dislocation  there  was  a  diffused  aneu- 
rism :  the  latter  was  unattended  by  any  pulsation,  so 
that  he  conjectured  the  artery  was  completely  torn 
across.  He  did  not  long  deliberate  as  to  what  course 
was  the  best  to  pursue  under  existing  circumstances, 
because  he  felt  sure  that,  so  far  as  the  torn  artery 
was  concerned,  if  the  head  of  the  humerus  was  once 
restored  to  its  place,  this  vessel  would  be  in  at  least 
as  favorable  a  condition  as  it  then  was ;  and  secondly, 
that  the  state  of  prostration  and  debility  the  patient 
was  in  at  that  moment,  offered  an  opportunity  which, 
if  once  lost,  might  not  again  be  afforded,  of  reducing 
easily  the  dislocation.  Taking  the  patient,  therefore, 
unawares,  the  writer  placed  his  knee  in  the  axilla  of 
the  dislocated  arm,  and  then,  slight  extension  having 
been  made  over  this  fulcrum,  the  bone,  at  the  first  trial, 
returned  into  the  glenoid  cavity.  The  patient  w^as 
placed  in  bed  in  the  Hospital,  under  the  care  of  the  late 
Mr.  Wallace,  whose  day  it  was  for  admitting  accidents. 
There  was  much  more  superficial  ecchymosis  about  the 
axillary  and  subclavian  regions,  and  along  the  inside  of 
the  left  arm,  than  is  usually  observed  after  a  simj)le 
dislocation  of  the  head  of  the  humerus.  The  deep  axil- 
lary swelling  remained  stationary  for  some  days,  but  no 
pulsation  could  be  discovered  either  in  it  or  in  the  arte- 
ries of  the  limb.  A  feeble  and  frequent  pulse  could  be 
felt  in  the  left  subclavian,  and  in  all  the  other  arteries, 
as  well  as  in  the  heart.     After  the  space  of  ten  days, 


196 


RIGHT   SUBCLAVIAN    AND    AXILLARY. 


Fig  2o.— Surgical  Anatomy  of  the  Rigid  Subclavian  and  Axillary  Arteries. 


A,  Subclavian  Vein  crossed  by  a  small  nerve  from  the  Brachial  Plexus  to  the  Subclavius  Muscle, 
■which  nerve  gives  a  branch  to  the  Phrenic.  B,  Subclavian  Artery  in  third  stage.  C,  Brachial 
Plexus  of  Nerves.  D,  Anterior  Scalenus  Muscle  with  the  Phrenic  Nerve  descending  upon  it,  and 
the  Supra  and  Posterior  Scapular  Arteries  crossing  both  :  the  Posterior  Scapular  in  this  case  came 
from  the  Thyroid  Axis:  this  is  its  usual  origin,  K,  Subclavius  Muscle.  F,  Insertion  of  Scalenus 
Amicus  Muscle  into  eminence  on  first  rib.  G,  Clavicular  origin  of  Deltoid  Muscle.  H,  Humeral 
attachment  of  Pectoralis  Major.  I,  Fascia  investing  the  Pectoralis  Minor.  K,  Thoracic  portion 
of  Pectoralis  Major.  L,  Coracoid  attachment  of  Pectoralis  Minor  divided  and  pendulous.  M, 
Coraco-brachialis  Muscle  and  Perforans  Casserii  Nerve.  N.  Biceps.  O,  Latiasimus  Dorsi  crossed 
by  the  Nerves  of  Wrisberg.  P,  Teres  Major  Muscle.  Q,  Brachial  Fascia.  R,  Sternal  end  of  Clavicle. 
S  Cephalic  Vein  passing  between  the  Deltoid  and  Great  Pectoral  Muscles,  and  then  in  front  of  the 
Pectoralis  Minor,  to  enter  the  Axillary  Vein,  a,  Axillary  Vein.  *a,  Basilic  Vein,  with  Internal 
Cutaneous  Nerve,  b,  Axillary  Artery  with  the  two  heads  of  the  Median  Nerve.  *b,  Brachial 
Artery  and  Veuse  Comites, 


BRANCHES   OF   THE   AXILLARY.  197 

Mr.  Wallace's  month  of  attendance  having  expired,  the 
case  came  under  the  care  of  Mr.  O'Reilly,  who,  having 
been  satisfied  that  a  diffused  aneurism  existed,  and  was 
on  the  increase,  performed  the  operation,  at  which  the 
writer  was  present,  of  tying  the  subclavian  artery  in 
the  third  stage  of  its  course.  The  patient  recovered 
and  was  discharged  from  the  hospital  about  two  months 
afterwards ;  he  lost  the  last  two  fingers  by  gangrene, 
but  whether  from  an  attack  of  erysipelas,  which  suc- 
ceeded the  operation,  or  from  the  effects  of  the  liga- 
ture of  the  main  artery  of  the  limb,  is  not  clearly 
known.  The  man  lived  for  many  years  afterwards  in 
the  immediate  vicinity  of  the  Eichmond  Hospital. 

The  axillary  artery  gives  off  the  following  branches : — 

Acromial,  or  Thoracica  Thoracica  Inferior. 

Acromialis.  Infra,  or  Sub-scapular. 

Thoracica  Suprema.  Posterior  Circumflex. 

Thoracica  Alaris.  Anterior  Circumflex. 

The  Acro7nial  or  Thoracica  acromialis  artery  arises  from 
the  axillary  in  its  first  stage;  it  is  a  short  thick  axis;  it 
arises  a  little  below  the  clavicle  and  passes  forwards 
above  the  edge  of  the  pectoralis  minor  muscle,  which  it 
separates  from  the  subclavius  muscle  and  ligamentum 
bicorne.  It  then  advances  towards  the  interval  between 
the  deltoid  and  pectoralis  major  muscles,  and  after  send- 
ing some  branches  to  the  serratus  magnus,  pectoral,  and 
subclavius  muscles,  it  terminates  by  dividing  into  a  supe- 
rior and  inferior  branch.  The  superior  branch  passes 
horizontally  outwards  beneath  the  deltoid  muscle,  and 
is  lost  in  supplying  the  latter  and  the  supra-spinatus 
muscle,  and  the  scapulo-humeral  and  acromio-clavicular 
articulations.  The  inferior  branch,  or  thoracica-humera- 
ria,  turns  spirally  round  the  cephalic  vein,  and  descends 
with  it  in  the  areolar  interval  between  the  deltoid  and 

17* 


198  BRANCHES   OP   THE   AXILLARY. 

great  pectoral  muscles,  and  is  distributed  to  these  mus- 
cles and  to  the  integuments.  The  acromial -artery  anas- 
tomoses with  the  supra-scapular  and  posterior  circumflex. 

The  Thoracica  Suprema  artery  arises  from  the  first 
stage  of  the  axillary ;  sometimes  it  arises  separately  a 
little  beneath  the  preceding,  but  more  frequently  it  is 
a  branch  of  the  acromial.  It  generally  runs  for  some 
distance  along  the  upper  margin  of  the  pectoralis  minor, 
and  then  descends  obliquely  inwards  between  it  and  the 
pectoralis  major,  to  both  of  which  muscles  it  sends  seve- 
ral branches ;  it  also  su^^plies  the  mammary  gland  and 
integuments,  and  anastomoses  with  the  intercostal  and 
internal  mammary  arteries. 

The  Thoracica  Alar  is  artery  \^  seldom  found  as  a  single 
trunk,  its  place  being  usually  supplied  by  several  smaller 
vessels  :  its  origin  is  from  the  second  stage  of  the  axil- 
lary. It  divides  into  many  branches  which  supply  the 
areolar  tissue  and  glands  of  the  axilla. 

In  removing  diseased  glands  from  this  cavity,  the  in- 
cautious division  of  the  branches  of  this  artery  may  be 
followed  by  smart  hemorrhage,  which  will  be  difficult 
to  control  on  account  of  the  divided  vessels  retracting 
into  the  areolar  tissue:  to  provide  against  this  occur- 
rence, Professor  Colles  advised  a  ligature  to  be  passed 
round  the  vessel  supplying  the  gland  before  it  is  divided. 

The  Thoracica  Inferior  j  called  also  the  thoracica  long  a 
or  external  mammary  artery,  arises  opposite  the  lower 
margin  of  the  pectoralis  minor,  or  frequently  whilst  the 
artery  is  under  cover  of  that  muscle  in  its  second  stage ; 
it  then  descends  obliquely  inwards,  concealed  by  the 
lower  edge  of  the  pectoralis  major:  it  supplies  these 
muscles,  and  likewise  the  serratus  anticus,  intercostals, 
mammary  gland  and  integuments,  and  anastomoses  with 
the  other  thoracic  arteries,  the  internal  mammary,  and 
the  intercostal  arteries. 


BRANCHES   OP   THE   AXILLARY.  199 

The  Infra  or  Subscapular  artery  is  of  considerable 
size  :  it  arises  from  the  third  stage  of  the  axillary,  oppo- 
site the  inferior  margin  of  the  sub-scapular  muscle,  to 
which  it  sends  one  or  two  branches,  and  then  descends 
along  the  inferior  margin  till  it  reaches  the  internal  edge 
of  the  long  head  of  the  triceps.  Here  it  divides  into 
an  inferior  and  posterior  branch :  the  inferior  branch 
continues  in  the  direction  of  the  trunk,  and  descends 
between  the  serratus  magnus  and  latissimus  dorsi  mus- 
cles, to  both  of  which,  and  to  the  teres  major,  its  branches 
are  distributed :  at  the  inferior  angle  of  the  scajDula  it 
anastomoses  with  the  posterior  scapular  artery.  The 
posterior  branch,  larger  than  the  inferior,  sinks  into  a 
triangular  space  bounded  above  by  the  teres  minor  and 
sub-scapular  muscles,  below  by  the  teres  major  and  latis- 
simus dorsi,  and  externally  by  the  long  head  of  the  tri- 
ceps, which,  in  this  situation,  separates  it  from  the  pos- 
terior circumflex  artery:  this  branch  supplies  freely  the 
muscles  bounding  this  triangular  space,  and  then  curves 
round  the  axillary  margin  of  the  scapula  to  arrive  in 
the  fossa  infra-spinata,  being  in  this  part  of  its  course 
covered  by  the  teres  minor  and  by  the  infra-spinatus 
muscle.  Here,  lying  close  to  bone,  it  divides  into  many 
branches,  which  supply  the  infra-spinatus  muscle  and 
shoulder-joint  and  anastomose  with  the  posterior  and 
superior  scapular  arteries.  The  infra  or  sub-scapular 
artery  sometimes  arises  in  common  with  the  posterior 
circumflex. 

The  Posterior  Circumflex  artery  is  a  little  smaller  than 
the  preceding  vessel,  and  arises  close  to  it  from  the 
posterior  part  of  the  axillary  artery  in  its  third  stage  : 
immediately  after  its  origin  it  sinks  into  a  quadrangular 
space,  bounded  above  by  the  sub-scapular  and  teres 
minor  muscles,  inferiorly  by  the  tendons  of  the  teres 
major  and  latissimus  dorsi,  anteriorly  by  the  humerus, 


200  THE    SCAPULAR   ANASTOMOSIS. 

and  posteriorly  by  the  long  head  of  the  triceps  :  in 
passing  through  this  space  it  winds  round  the  surgical 
neck  of  the  humerus,  accompanied  by  the  posterior  cir- 
cumflex nerve.  After  giving  a  few  branches  to  the  teres 
minor  and  sub-scapularis  muscles,  and  to  the  shoulder- 
joint,  it  sinks  beneath  the  deltoid  muscle,  into  which  it 
sends  numerous  branches,  which  anastomose  with  the 
supra-scapular,  acromial,  and  anterior  circumflex  arte- 
ries. 

The  Anterior  Circumflex  artery  is  a  very  small  but  very 
constant  branch :  it  passes  horizontally  forwards  and 
outwards,  covered  by  the  coraco-brachialis  muscle  and 
short  head  of  the  biceps.  It  then  crosses  the  bicipital 
groove,  covered  by  its  synovial  membrane  and  by  the 
long  head  of  the  biceps,  and  sinks  beneath  the  deltoid 
muscle,  in  the  substance  of  which  it  anastomoses  with 
the  posterior  circumflex  artery.  The  anterior  circum- 
flex artery  supplies  the  coraco-brachialis,  biceps,  and 
sub-scapularis  muscles.  While  crossing  behind  the  long 
head  of  the  biceps,  it  sends  a  delicate  branch  upwards 
along  the  bicipital  groove,  to  supply  the  head  of  the 
humerus  and  capsular  ligament  of  the  shoulder-joint. 

It  will  be  useful  in  the  present  stage  of  the  dissection 
to  take  a  glance  at  the  principal  arteries  which  form 
what  is  termed  the  scapular  anastomosis.  'By  means  of 
this  free  arterial  communication  around  the  scapula,  the 
blood  of  the  subclavian  artery  will  readily  find  its  way 
into  the  arm  or  fore-arm  in  cases  where  the  subclavian 
has  been  tied  in  its  second  or  third  stages,  or  where  the 
axillary  artery  has  been  tied  in  its  first  or  second  stages. 
Along  the  axillary  margin  of  the  scapula  we  observe  the 
continued  branch  of  the  sub-scapular  artery  passing 
towards  the  inferior  angle  of  that  bone:  along  the  pos- 
terior or  vertebral  margin  we  see  the  posterior  scapular 
passing  towards  the  same  point;  and  in  relation  with 


THE    SCAPULAR   ANASTOMOSIS. 


201 


Pig.  26. — Represents  the  Arteries  of  the  Posterior  part  of  the  Neclc  and  Shoulder.- 
The  Scapxdar  Anastomosis. 


1,  1,  Occipital  portion  of  Trapezius  Muscle  of  each  side.  2,  2,  2,  Arterial  branches  to  the  Trapezius 
and  Latissinius  Dorsi  Muscles.  3,  Sterno-cleido-niastoid  Muscle.  4,  Splenius  Capitis.  3,  Splcniua 
Colli.  6,  6,  Levator  Anguli  Scapulae.  7,  Lower  portion  of  Sterno  mastoid.  8,  Serratus  Posticus 
Superior.  9,  Rhomboideus  Minor.  10,  Rhomboideus  Major  divided.  11,  11,  Aponeurosis  covering 
long  Muscles  of  Back.  12,  Clavicle  with  Arterial  twig.  1.3,  U.  Spine  of  Scapula  with  Arterial  Twigs. 
15,  Insertion  of  Infraspinatus  Muscle.  16,  Capsule  of  shoulder-joint.  17,  Teres  Minor.  18,  Long 
Head  of  Triceps  between  the  two  Teres  Muscles.  19,  Teres  Major.  20,  Deltoid  divided  and  turned 
downwards.  21,  21  21,  Serratus  Magnus  with  Arterial  Twigs.  22,  Latissinius  Dorsi  divided  and 
turned  over.  a.  Occipital  Artery  emerging  from  underneath  the  Splenius  Muscle  to  get  into  its  third 
stage,  b,  b,  Posterior  Scapular  Artery,  c,  c,  c.  Terminating  branch  of  the  Posterior  Scapular 
Artery.  d,e,  Cervicalis  Superlicialis  Artery  cut.  f,  Twig  to  the  Clavicle,  g  Small  branch  to  Supra- 
spinatus.  i,  Supra-scapular  Artery,  k,  Infra-Spinata  Artery.  1,  Acromion  Process,  ni.  Posterior 
Circumflex  Artery,  n,  n,  Anastomoses  between  the  Infra-spinata,  the  Posterior  branch  of  Subsca- 
pular and  Posterior  Scapular  Arteries,  o,  o,  Branches  of  the  Intercostal  Arteries.  P,  P,  P,  Dorsal 
branches  of  the  Intercostal  Arteries. 


202  VEINS   OF   THE    ARM    AND    FORE-ARM. 

the  superior  or  coracoid  margin  we  find  the  supra-scapular 
artery.  At  the  inferior  angle  of  the  scapula  a  free  commu- 
nication exists  between  the  posterior  scapular  and  sub-sca- 
pular arteries;  at  the  posterior  superior  angle  a  similar  com- 
munication exists  between  the  posterior  and  supra-scapular 
arteries;  and  at  the  glenoid  angle,  underneath  the  root  of 
the  acromial  process,  a  free  anastomosis  takes  place  between 
the  supra-scapular  and  the  sub-scapular  arteries.  Thus  the 
axillary  and  subclavian  arteries  communicate  freely  with  each 
other. 

VEINS   OF   THE   ARM   AND   FORE-ARM. 

Before  proceeding  with  the  dissection  of  the  brachial 
artery  the  student  is  recommended  carefully  to  examine  the 
superficial  veins  of  the  arm  and  fore-arm ;  for  this  purpose 
he  should  remove  the  integuments  from  off  the  front  of 
these  parts,  when  the  veins  and  superficial  nerves  will  be 
exposed  lying  between  the  skin  and  fascia. 

VencesectioR  is  usually  performed  at  the  bend  of  the  elbow, 
because  there  are  in  this  situation  a  number  of  superficial 
veins,  easily  made  prominent  and  easily  compressed.  On  the 
outside  of  the  bend  of  the  elbow  we  observe  the  cephalic  veiiij 
ascending,  having  derived  its  principal  origin  from  the  cephalic 
vein  of  the  thumb.  On  the  inside  we  see  the  basilic  vein, 
which  seems  to  be  a  continuation  of  the  small  vein  of  the 
little  finger,  termed  vena  salvatella.  On  the  middle  line  of 
the  front  of  the  fore-arm  we  see  the  median  vein,  which,  as 
it  approaches  the  elbow-joint,  divides  into  an  internal  and  ex- 
ternal branch  :  the  infernal  branch  is  the  median  basilic  vein; 
it  crosses  in  front  of  the  brachial  artery  at  a  very  acute  angle, 
being  separated  from  it  immediately  beneath  the  bend  of  the 
elbow,  by  the  semilunar  process  of  the  biceps  tendon,  called 
also  the  semilunar  fascia  of  the  biceps  :  some  of  the  branches 
of  the  internal  cutaneous  nerve  pass  in  front  of  it,  and  others 
behind  it.     The  external  branch,  smaller  than  the  internal,  is 


VEINS    OF    THE   ARM    AND    FORE-ARM. 


203 


termed  the  median-cephalic  vein  ;  it  ascends  obliquely  upwards 
and  outwards,  in  front  of  the  trunk  of  the  external  cutaneous 
nerve,  to  join  the  cephalic  vein.  The  basilic  and  cephalic 
veins,  being  thus  reinforced,  ascend 
in  the  arm,  the  former  along  the  in- 
ternal and  the  latter  along  the  ex- 
ternal margin  of  the  biceps  muscle. 
The  basilic  vein  unites  with  the  vena? 
comites  of  the  brachial  arteiy,  and 
the  large  vessel  formed  by  their 
union  becomes  the  axillary  vein. 

In  the  middle  of  the  fore-arm, 
near  the  bend  of  the  elbow,  the 
median  vein,  before  it  gives  off  its 
median  basilic  and  median  cephalic 
veins,  receives  at  its  posterior  sur- 
face, from  the  deep-seated  parts  of 
the  fore-arm,  a  vein  called  the  me- 
diana  profunda. 

When  the  operation  of  venaesec- 
tion  is  determined  on,  the  student 
will  observe  that  the  median  basilic 
is  the  vein  which  presents  itself 
most  prominently;  and,  if  this  be 
selected  for  the  operation,  great 
caution  will  be  necessary,  in  order 
to  avoid  wounding  the  brachial 
artery,  which  lies  beneath  it.  On 
this  account  the  student  is  advised 


Fig.  21  .—Represents  portion  of  the  Surgical 
Anatomy  of  the  Fore-arm. 

A,  Fascia  over  the  Biceps  Muscle.  B,  Basilic  Vein  and 
Internal  Cutaneous  Nerve.  C.  Brachial  Artery  and  the 
Venae  Comites.  D,  Cephalic  Vein  and  External  Cutaneous 
Nerve  coming  out  from  behind  it.  E,  Median  Cephalic 
Vein  and  a  communicating  vein  to  the  Vense  Comites.  P. 
Median  Basilic  Vein.  G,  Radial  Artery.  H.  Lymphatic 
Gland.  1,  Radial  Artery  seen  lhrough"an  opening  made 
in  the  fascia.  K,  Ulnar  Artery  and  Ulnar  Nerve.  L, 
Palniaris  Brevis  Muscle. 


204  BRACHIAL   ARTERY. 

to  select  the  median  cephalic  vein  in  preference,  at  all  events 
until  he  has  become  somewhat  expert  in  performing  the  ope- 
ration. A  wound  of  the  artery  during  vensesection  may  be 
denoted  by  the  blood  issuing  in  jerks,  and  being  of  a  bright 
arterial  color.  These  appearances  may  exist,  however,  with- 
out any  such  wound,  and  therefore  need  not  always  excite 
alarm :  on  the  contrary,  the  artery  may  be  punctured  without 
any  particular  symptom  to  indicate  the  accident.  When  there 
is  reason, /rom  the  great  force  with  which  the  blood  is  pro- 
jected, to  suspect  that  this  accident  has  occurred,  and  there  is 
no  pain,  swelling,  nor  effusion  present,  we  may  apply  a  gra- 
duated compress,  keep  the  limb  quiet,  and  wait  the  result, 
which  may  be  various.  Sometimes  the  wounded  vessel  may 
heal  without  any  unpleasant  consequence :  in  other  cases,  the 
external  wound  of  the  vein  is  healed,  but  the  wound  in  the 
posterior  wall  of  the  vein  may  form  an  adhesion  with  the 
wound  in  the  anterior  wall  of  the  artery,  and  thus  there  re- 
mains a  direct  communication  between  the  artery  and  vein. 
When  this  direct  communication  exists  between  the  two 
vessels,  the  affection  is  termed  aneurismal  varix;  but  if  the 
areolar  tissue  intervening  between  the  two  vessels  has  been 
distended  into  the  form  of  a  sac,  which  establishes  a  medium 
of  communication  between  the  artery  and  vein,  then  the 
disease  is  termed  varicose  aneurism.  The  latter  is  the  more 
serious,  as  it  may  terminate  in  aneurism  of  the  artery;  but  it 
is  seldom  that  either  of  them  requires  any  operation. 

The  student  may  now  remove  the  veins  and  brachial  apo- 
neurosis, so  as  to  expose  the  brachial  artery. 


THE   BRACHIAL   ARTERY. 

This  artery  is  a  continuation  of  the  axillary :  it  commences 
opposite  the  lower  margin  of  the  teres  major  and  latissimus 
dorsi  tendons,  passes  obliquely  downwards  and  outwards,  and 
terminates  nearly  opposite  the  coronoid  process  of  the  ulna: 


BRACHIAL   ARTERY.  205 

on  the  removal  of  the  integuments,  the  artery  will  be  found 
lying  under  cover  of  the  brachial  aponeurosis.  After  the 
aponeurosis  has  been  removed,  the  vessel  will  be  seen  over- 
lapped by  the  fleshy  belly  of  the  coraco-brachialis  muscle, 
then  by  the  biceps  muscle,  and  still  lower  down  covered  by 
the  semilunar  fascia  derived  from  the  tendon  of  the  biceps  : 
these  are  its  anterior  relations  :  internally  it  is  related,  in 
addition  to  the  integuments  and  fascia,  to  the  basilic  vein,  tc^ 
the  inferior  profunda  artery,  and  to  the  ulnar  and  internal 
cutaneous  nerves;  externally  it  is  related  to  the  coraco-bra- 
chialis and  biceps  muscles,  and  to  an  areolar  interval  placed 
between  the  biceps  and  brachialis  anticus :  'posteriorly  it  cor- 
responds first,  to  the  triceps  muscle,  from  which  it  is  separated 
by  the  superior  profunda  artery  and  musculo-spiral  nerve; 
next  it  rests  on  the  insertion  of  the  coraco-brachialis  muscle ; 
and,  in  the  remainder  of  its  course,  it  lies  upon  the  brachialis 
anticus. 

The  brachial  nerves  surround  the  artery,  and  are  related  to 
it  in  the  following  order :  behind  it,  but  accompanying  it 
merely  for  a  short  distance,  is  the  musculo-spiral  nerve  :  the 
external  cutaneous  nerve  at  first  descends  along  its  outer  side, 
separating  it  from  the  coraco-brachialis  muscle;  but  lower 
down,  it  inclines  outwards,  perforates  the  last-named  muscle, 
and  loses  its  relation  to  the  artery.  The  internal  cutaneous 
nerve  lies  at  first  on  the  inside  of  the  artery,  being  situated 
on  the  front  of  the  ulnar  nerve,  which  it  consequently  sepa- 
rates from  the  median :  lower  down,  the  branches  of  the 
internal  cutaneous  nerve  become  superficial,  and  one  principal 
filament  covers  the  artery  at  its  termination.  The  ulnar 
nerve  descends  on  the  inside  of  the  vessel,  but  towards  the 
middle  of  the  humerus  separates  from  it,  and  inclines  still 
more  internally,  and  accompanies  the  inferior  profunda 
artery ;  and  lastly,  the  median  nerve  lies  on  the  outside  of 
the  brachial  artery  above ;  but  lower  down,  at  about  the  juncr 
tion  of  the  lower  with  the  two  upper  thirds  of  the  arm,  it 

IS 


206 


BRACHIAL   ARTERY. 


crosses  the  artery,  usually  over  its  anterior  surface,  in  order 
to  arrive  at  the  iriner  side  of  the  vessel.  The  veins  accom- 
panying the  artery  are  two  in  number,  and  are  termed 
vense  comites :  about  the  middle  of  the  arm  they  unite  with 
the  basilic  vein,  which  usually  per- 
forates the  brachial  aponeurosis  in  this 
situation.  Such  are  the  relations  of 
the  brachial  artery  in  its  course  down 
the  arm.  At  its  termination  it  sinks 
into  a  triangular  space,  in  front  of  the 
elbow-joint,  bounded  on  the  outside 
by  the  supinator  radii  longus,  and  on 
the  inside  by  the  pronator  radii  teres 
muscle;  the  latter  muscle  overlapping 
the  artery  in  this  situation.  In  this 
space  it  lies  on  the  brachialis  anticus 
muscle,  having  the  tendon  of  the  biceps 
to  its  outside,  the  median  nerve  to  its 
inside,  while  in  front  it  is  covered  by 


Fig.  28. — Represents  the  Arteries  of  the  upper  ex- 
tremity, which  are  seen  when  the  skin  and  fascia 
have  been  removed. 


A  A,  Brachial  or  Humeral  Artery.    B  B,  Radial  Art«ry.     C, 
Ulnar  Artery.     K.  Muscular  branch  to  the  Brachialis  Auticus. 

0,  SuperUcialis  Vola;  Artery.  P  P,  The  Superficial  Palmar 
Arterial  Arch,  formed  by  the  Ulnar  and  Superficialis  Vola 
Arteries.  Q,  Digital  Artery  of  thumb.  S,  Twig  to  the  Palmaris 
Brevis  Muscle.  V,  Priuceps  Pollicis  Artery,  running  along  the 
internal  margin  of  the  thumb,  a,  Twig  to  the  Triceps,  b, 
Small  branch  to  Coraco-brachialis  and  Biceps,  c,  Superior 
Profunda  about  to  euter  between  the  two  portions  of  the  Triceps, 
d.  Inferior  Profunda,  arising  opposite  the  insertion  of  the  Coraco- 
brachialis  Muscle,  e,  f,  Muscular  Branches,  g,  h.  Small  twigs 
to  the  Biceps,  i,  Tlie  Anastomotic  Artery.  1,  Radial  Recur- 
rent Artery,  m,  Twig  to  the  Pronator  Teres  and  Flexor  Carpi 
Radiali.s  Muscles,  n,  Branch  to  the  Supinator  Radii  Longus. 
r,  The  Radialis  Indicis  Artery,  t,  t,  t,  t,  The  four  Digital 
Arteries,    u,  u,  u,  u,  The  arches  formed  by  the  Digital  Arteries. 

1,  Portion  of  Pectoralis  Major.  2,  The  Deltoid  Muscle.  3,  Upper 
portion  of  Biceps  Muscle.  4,  Coraco-brachialis.  5,  Triceps. 
6,  Belly  of  Biceps.  7,  Internal  Intermuscular  Septum.  8,  Short 
portion  of  Triceps.  9,  Brachialis  Anticus.  10,  Tendon  of 
Biceps.  11,  Semilunar  Fascia  from  Biceps  Tendon.  12,  Pro- 
nator Teres.  13,  Internal  Condyle.  14,  Supinator  Radii 
Longus  Muscle.  15,  Pronator  Teres  crossed  by  Radial  Artery. 
16,  Flexor  Carpi  Radialis.  17.  Palmaris  Longus.  18,  Flexor 
Carpi  Ulnaris.  19,  Extensor  Carpi  Radialis  Longior.  20,  Por- 
tion of  Flexor  Digitorura  Sublimis,  or  Perforatus.  21,  Extensor 
PrimI  Internodii  Pollicis.  22,  Extensor  Ossis  Metacarpi  Pollicis. 
23,  Palmar  Aponeurosis.  24,  Tendons  of  the  Superficial  Flexor, 
crossed  by  the  Superficial  Palmar  Arch  of  Arteries. 


LIGATURE  OP   BRACHIAL  ARTERY.  207 

an  aponeurotic  slip  of  a  semilunar  form,  sent  downwards  and 
inwards  from  the  teudon  of  the  biceps  muscle  to  join  the 
anti-brachial  aponeurosis  a  little  below  the  internal  condyle : 
this  is  called  the  semilunar  fascia  of  the  biceps )  its  upper 
margin  is  concave  and  directed  upwards  and  inwards;  its 
insertion  into  the  fascia  of  the  fore-arm  is  much  broader  than 
its  origin  from  the  tendon  of  the  biceps. 

The  Operation  of  tying  the  Brachial  artery.  This  opera- 
tion may  become  necessary  for  the  cure  of  aneurisms  of  this 
vessel,  or  in  consequence  of  a  wound  inflicted  on  it  or  upon 
the  radial,  ulnar,  or  interosseous  arteries. 

True  Aneurism  of  the  brachial  artery,  or  that  form  of  the 
disease  which  consists  in  a  dilatation  of  all  the  coats  of  the 
vessel,  is  extremely  rare  :  Pelletan  mentions  an  example  of  it 
in  his  "  Clinique  Chirurgicale,"  which  Dupuytren  stated  was 
the  only  authentic  case  of  the  kind  he  knew  of.* 

Aneurism  of  the  Brachial  artery  depending  upon  a  dis- 
eased condition  of  its  coats,  is  also  very  rare.  Mr.  Listen 
observes,  "  I  have  treated  but  one  such  case ;  it  occurred  in 
the  person  of  an  old  ship-carpenter.  Whilst  at  work  as 
usual,  he  felt  something  snap  in  his  arm ;  a  pulsating  tumor 
was  soon  afterwards  noticed,  and  before  I  was  asked  to  see 
him  by  Mr.  Cheyne,  of  Leith,  it  had  attained,  during  four 
months,  fully  the  size  of  a  hen^s  eg^,  and  was  evidently  in 
part  composed  of  solid  matter.  The  brachial  was  tied  and 
every  thing  went  on  favorably ."f 

Diffused  False  Aneurism.  By  far  the  most  frequent  forms 
of  aneurism  of  the  brachial  artery  are  those  which  are  the 
result  of  injuries  inflicted  upon  the  vessel,  as  in  the  operation 
of  vensesection  at  the  bend  of  the  elbow.  When  the  artery 
has  been  unfortunately  wounded,  the  following  results  may 
happen  :  the  blood  may  escape  freely  from  the  wound  in  the 


*  Lemons  Orales,  vol.  i.  p.  265.  f  Prac.  Surg.  p.  206. 


208        ANEURISMS  OP  BRACHIAL  ARTERY. 

artery,  and  may  pass  into  the  areolar  tissue  of  the  limb  to  a 
greater  or  less  extent :  in  some  cases  the  extravasation  of 
arterial  blood  is  so  considerable  as  to  reach  nearly  as  high  up 
as  the  folds  of  the  axilla,  and  for  a  certain  distance  also  below 
the  elbow-joint;  this  has  been  termed  vl  diffused  false  aneu- 
rism. This  form  of  aneurism  may  occur  also,  from  too  great 
an  amount  of  pressure  having  been  applied  to  the  sac  for  the 
cure  of  the  next  variety  we  shall  speak  of,  namely,  the  cir- 
cumscribed false  aneurism,  the  sac  gives  way  and  the  blood 
becomes  diffused  through  the  limb.  An  instance  of  this  kind 
is  recorded  by  Mr.  Ellis,  one  of  the  surgeons  to  Jervis  Street 
Hospital ;  he  observes,  "  the  pressure  having  been  too  forcibly 
applied,  the  sac  gave  way  and  a  diffused  aneurism  became 
established."* 

Circumscribed  False  Aneurism.  After  the  infliction  of  a 
wound  upon  the  artery,  the  blood  may  escape  at  once  directly 
through  the  external  wound;  if  pressure  be  now  made  upon 
the  wound,  the  general  diffusion  of  the  blood  may  be  pre- 
vented, and  a  process  of  thickening  may  be  set  up  in  the 
areolar  membrane  surrounding  the  small  quantity  of  blood 
which  has  insinuated  itself  between  the  wound  in  the  artery 
and  the  integuments;  this  thickened  areolar  membrane  be- 
comes matted  together  by  the  effusion  of  coagulable  lymph, 
and  is  ultimately  converted  into  the  cyst  of  the  aneurism, 
which  communicates  with  the  canal  of  the  wounded  artery : 
this  has  been  termed  a  circumscribed  false  aneurism. 

Aneurismal  Varix,  and  Varicose  Aneurism,  form  two 
other  varieties  of  aneurismal  tumors  resulting  from  a  wound 
of  the  artery  during  venassection ;  these  two  have  been 
already  considered :  the  student  will,  however,  do  well  to  re- 
collect that  in  the  former  there  is  a  direct  communication 
between  the  artery  and  the  vein,  whilst  in  the  latter  an  inter- 
vening  sac  is  situated  between  the  two  vessels. 

«  Clin.  Sur.,  p.  69. 


TREATMENT   OF   BRACHIAL   ANEURISMS.  209 

We  shall  now  consider  the  treatment  applicable  to  these 
four  varieties  of  brachial  aneurism,  the  results  of  wounds  in- 
flicted upon  the  artery. 

With  regard  to  the  circumscribed  false  aneurism,  Pro- 
fessor Harrison  remarks^  "  I  do  not  recollect  a  case  of  this 
sort  of  circumscribed  aneurism,  from  the  infliction  of  a 
simple  wound,  in  which  it  has  been  necessary  to  open  the 
sac  or  tie  the  artery  below  it;  I  am,  therefore,  disposed  to 
place  full  reliance  on  the  practice  of  simply  laying  bare  the 
vessel  as  close  to  the  tumor  as  circumstances  will  permit,  and 
tying  it  with  a  single  ligature."  Professor  Colles,  whose  ex- 
perience and  great  opportunity  for  observation  render  every 
practical  remark  of  his  worthy  of  attention,  thus  expresses 
himself  on  this  subject  in  his  course  of  lectures  on  the 
Theory  and  Practice  of  Surgery :  "  I  have  operated  repeatedly, 
and  with  success,  for  the  cure  of  circumscribed  brachial 
aneurism,  in  consequence  of  injury  to  the  artery  in  perform- 
ing venaesection ;  I  have  also  frequently  assisted  others  in 
operating  for  the  same  cause,  and  with  the  same  result;  and 
I  never  yet  found  it  necessary  to  open  the  aneurismal  sac,  or  to 
look  for  the  vessel  below  the  tumor,  or  to  apply  more  than  one 
ligature  around  the  artery,  which,  I  think,  ought  always  to 
be  tied  as  near  as  possible  to  the  seat  of  the  disease ;  for  in 
this  species  of  aneurism  the  coats  of  the  vessel  have  not 
undergone  any  morbid  change,  as  is  generally  the  case  in 
aneurism  of  the  inferior  extremity."* 

Mr.  Cusack  has  treated  three  cases  of  circumscribed 
aneurism  at  the  bend  of  the  elbow  from  wounds  in  venaesec- 
tion,  by  compression.-\  The  compresses  were  applied  chiefly 
upon  the  tumor,  the  compressing  force  was  moderate;  the 
limb  was  bandaged  with  the  "  gantelet,"  from  the  fingers  up- 
wards, according  to  Genga's  method :  blood  was  taken  from 

*  Surgical  Anatomy  of  the  Arteries,  pp.  185-6 
t  Dublin  Journal,  vol.  i.  pp.  117,  &c. 

18* 


210  TREATMENT   OP   BRACHIAL   ANEURISMS. 

the  patient  by  vensesection,  digitalis  administered,  and  abso- 
lute rest  and  low  diet  enjoined.  The  two  first  cases  termi- 
nated favorably  under  this  treatment;  during  the  treatment 
of  the  third  case,  the  circumscribed  aneurism  became  diffused. 
Scarpa  adopted  this  mode  of  compression  for  the  cure  of  cir- 
cumscribed brachial  aneurisms.  The  method  of  treating 
aneurism,  by  compression  of  the  artery  leading  to  the  aneuris- 
mal  sac,  has  been  successfully  employed  by  Dr.  Hutton  in  a 
case  of  circumscribed  aneurism  of  the  brachial  artery  at  the 
bend  of  the  elbow:  the  patient  was  a  servant  aged  thirty-four; 
he  had  been  bled  by  a  ^'  country  bleeder"  for  a  pain  in  the 
chest.  On  his  admission  into  the  Richmond  Hospital,  the 
aneurismal  tumor  was  circumscribed  and  about  the  size  of  a 
pullet's  egg;  it  pulsated  strongly  and  presented  the  usual 
characters  of  aneurism.  Dr.  Carte's  compressing  apparatus 
was  employed ;  "  with  this  the  patient  maintained  the  com- 
pression during  six  hours  in  succession ;  at  the  end  of  this 
period  all  pulsation  had  ceased  and  never  returned,'^*  If, 
however,  these  methods  should  fail  in  obliterating  the  sac  of 
a  circumscribed  brachial  aneurism,  the  surgeon  may  tie  the 
artery  leading  to  the  tumor  with  a  single  ligature ;  and  in  ad- 
dition, compression  of  the  entire  limb,  from  the  fingers  as  far 
as  the  elbow,  should  be  employed. 

Surgeons  are  now  generally  agreed  as  to  the  proper  mode 
of  treatment  in  cases  of  diffused  false  aneurism  of  the* 
brachial  artery ;  the  single  ligature,  which  may  be  sufficient 
in  the  circumscribed  aneurism,  is  not  to  be  depended  on  in 
this  form.  When  the  wound  in  the  vessel  is  large,  when  the 
extravasation  of  blood  becomes  considerable,  when  the  tume- 
faction of  the  limb  extends  upwards  along  the  arm,  and  occu- 
pies also  the  upper  portion  of  the  fore-arm,  accompanied  with 
pain  and  discoloration  of  the  integuments,  compression  will  be 
worse  than  useless,  and  the  single  ligature  on  the  artery  lead- 

*  Medical  Press  for  May  16,  1849. 


TREATMENT   OP   BRACHIAL   ANEURISMS.  211 

ing  to  the  wound  will  not  suffice ;  the  free  anastomoses  of 
the  vessels  about  the  elbow-joint  will  allow  the  blood  to  flow 
freely  from  the  wounded  artery,  and  the  hemorrhage  will  con- 
tinue without  control.  In  a  case  of  this  description,  there- 
fore, the  only  operation  which  can  with  confidence  be  relied 
on,  is  to  cut  down  with  a  free  incision  upon  the  wounded 
vessel,  to  turn  out  the  coagulum  of  blood,  and  to  tie  the 
artery  above  and  below  the  wound.  In  speaking  on  this  sub- 
ject Professor  Harrison  observes  :  "  I  now  believe  that  very 
few  cases  of  difi"used  aneurism,  either  of  this  or  any  other 
artery,  will  admit  of  cure  from  the  simple  operation  and  ap- 
plication of  a  single  ligature  to  the  artery  above  the  injured 
part,  but  that  it  will  be  almost  always  necessary  to  lay  open 
the  tumor  by  a  long  incision,  which  should  include,  if  possible, 
the  original  wound.  When  the  injured  vessel  shall  have  been 
exposed,  it  may  be  raised  by  a  probe,  either  introduced  into 
it  through  the  wound,  or  the  aneurism-needle  can  be  passed 
around  it,  and  the  artery  tied  first  above  and  then  below  the 
opening."*  Professor  Porter  observes :  "  But  there  is  still 
another  case ;  and  let  us  suppose  a  limb,  into  which  a  quantity 
of  blood  has  been  extravasated,  not  sufficient  to  cause  a  gan- 
grene of  the  part,  but  still  too  abundant  to  admit  a  hope  of  its 
being  absorbed.  Here,  I  apprehend,  the  surgeon  has  no 
choice ;  he  must  cut  down,  turn  out  all  the  coagula  he  can 
reach,  in  this  way  getting  rid  of  that  which  would  be  a  sub- 
sequent source  of  irritation,  and  then  tie  the  vessel  above  and 
below  the  aperture.'^f 

We  are  anxious,  however,  to  impress  upon  the  mind  of  the 
student,  that  in  cases  of  simple  puncture  of  the  brachial 
artery,  as  in  venaesection,  or  where  there  is  no  extensive  effu- 
sion of  arterial  blood  to  create  alarm,  there  is  no  necessity  for 
immediate  operation.     The  constitutional  disturbance  conse- 


*  Surgical  Anatomy  of  the  Arteries,  pp.  180,  &c. 
t  Porter  on  Aneurism,  p.  138. 


212  TREATMENT    OF   BRACHIAL   ANEURISMS. 

quent  upon  the  wound,  and  the  alarm  into  which  the  patient 
is  thrown  from  the  agitation  and  terror  betrayed  by  the  un- 
successful operator,  at  the  instant  when  he  is  aware  of  the 
mischief  he  has  done,  added  to  the  shock  sustained  by  the 
alarm  and  precipitancy  of  a  hasty  operation  performed  under 
such  circumstances, — all  contribute  to  induce  such  a  state  of 
the  patient's  system  as  to  render  it  very  unfavorable  for  the 
healing  of  the  wound,  and  secondary  hemorrhage  has  been 
known  to  result  from  such  unnecessary  interference.  In 
cases,  therefore,  not  demanding  immediate  operation,  the 
student  is  recommended  to  apply  judicious  compression  by 
means  of  graduated  compresses  laid  carefully  one  over  the 
other  upon  the  wound,  so  as  to  correspond  to  the  orifice  of  the 
bleeding  vessel,  and  to  surround  all  by  means  of  a  figure  of  8 
bandage,  coiled  round  the  elbow  a  sufficient  number  of  times 
to  secure  the  compresses  in  their  proper  situation.  Another 
form  of  bandage  has  been  preferred  by  some  surgeons :  it  is 
called  the  ^^  gantelet'^  of  Genga ;  it  consists  of  narrow  strips  of 
bandage  with  which  each  finger  was  enveloped  separately; 
these  met  above  the  wrist,  from  which  point  a  broader  roller 
was  carried  round  the  fore-arm,  and  round  the  elbow  over  the 
compresses  which  had  been  previously  applied ;  the  bandage 
was  also  carried  round  the  arm  up  towards  the  axilla.  This 
mode  of  treatment  by  compression,  in  conjunction  with  pro- 
per position,  absolute  rest,  low  diet,  &c.,  has  proved  in  such 
cases  decidedly  successful,  and  until  it  fail,  the  operation  is 
unnecessary  and  may  be  mischievous. 

With  regard  to  the  treatment  required  for  aneurismal 
varix,  and  for  the  varicose  aneurism,  we  have  already  ob- 
served that  it  is  seldom  that  either  of  them  requires  any 
operation:  the  method  of  compression  already  alluded  to, 
either  upon  the  diseased  part  or  upon  the  brachial  artery 
leading  to  it,  may  be  employed  with  considerable  advantage. 
Dr.  William  Hunter  advised  that  nothing  should  be  done  in 
the  way  of  operation  in  these  cases  where  there  should  be  no 


LIGATURE   OP   THE   BRACHIAL   ARTERY.  213 

considerable  alteration  in  the  tumor.  Sir  A.  Cooper  enter- 
tained the  same  objection  to  the  operation.  If,  however,  the 
disease  should  continue  to  increase  in  size,  if  a  thinning  of 
the  integuments  over  the  tumor,  or  over  the  sac,  as  in  the 
varicose  aneurism,  should  occur  so  as  to  threaten  an  eflfusion 
of  blood  into  the  limb,  or  from  an  ulcerated  opening  in  the 
integuments,  the  surgeon  will  be  obliged  to  tie  the  brachial 
artery,  not  with  a  single  ligature  passed  round  the  vessel  lead- 
ing to  the  aneurism,  but  having  cut  into  the  sac  and  having 
turned  out  the  coagulum,  he  should  tie  the  artery  both  above 
and  below  the  wound  in  the  vessel. 

Operation  of  tying  the  Brachial  Artery  in  the  superior 
third  of  the  arm.  The  arm  being  abducted  and  rotated  out- 
wards for  the  purpose  of  diminishing  the  depth  of  the  wound, 
an  incision,  about  two  inches  and  a  half  long,  may  be  made 
over  the  ulnar  margin  of  the  coraco-brachialis  muscle,  the 
belly  of  which  may  be  felt  through  the  integuments.  This 
should  be  done  with  much  caution,  as  the  integuments  are 
thin  in  this  situation,  and  the  basilic  vein  may  sometimes, 
though  rarely,  lie  superficial  to  the  brachial  aponeurosis; 
moreover,  the  internal  cutaneous  nerve  lies  here  immediately 
underneath  the  skin.  The  fascia  being  next  divided  on  a 
director  to  the  same  extent,  the  areolar  tissue  may  be  scraped 
through  with  the  handle  of  a  knife  till  the  artery  and  nerves 
are  brought  into  view.  The  vein  formed  by  the  union  of  the 
basilic  vein  with  the  venae  comites,  together  with  the  internal 
cutaneous  and  ulnar  nerves,  may  be  drawn  to  the  inside,  and 
the  median  nerve  to  the  outside,  and  the  needle  passed  from 
within  outwards.  The  separation  of  the  artery  and  nerves 
will  be  facilitated  by  flexing  the  limb. 

The  operator  will  bear  in  mind  the  possibility  of  a  high 
bifurcation,  and  of  the  superior  profunda  artery  arising  from 
the  posterior  circumflex  and  assuming  the  position  of  the 
brachial  artery. 


214  LIGATURE   OF   THE   BRACHIAL   ARTERY. 

Ligature  of  the  Brachial  Artery  in  the  middle  of  the  arm. 
The  elbow-joint  being  extended  and  the  arm  rotated  outwards, 
an  incision  should  be  made,  about  two  inches  and  a  half  long, 
on  the  internal  margin  of  the  biceps  muscle.  Having  divided 
the  integuments  and  drawn  the  vein  or  veins  out  of  the  way, 
the  fascia  should  next  be  divided  on  a  director.  In  some 
cases  the  basilic  vein  lies  beneath  the  fascia  in  this  situation. 
By  drawing  outwards  the  biceps  muscle  with  a  blunt  retractor, 
the  artery  may  be  exposed,  with  a  small  vein  frequently  lying 
on  either  side,  and  the  median  nerve  usually  in  front  of  it. 
The  nerve  is  to  be  drawn  to  the  inside,  and  the  needle  passed 
from  within  outwards.  The  operator  should  remember  that 
internal  and  posterior  to  the  brachial  artery,  in  this  situation, 
the  inferior  profunda  artery  descends  in  .company  with  the 
ulnar  nerve,  the  nerve  lying  to  the  inner  side :  to  avoid  tying 
the  latter  artery  in  mistake,  he  should  first  take  care  to  direct 
the  edge  of  his  knife,  not  backwards,  but  towards  the  centre 
or  axis  of  the  humerus,  and  afterwards  satisfy  himself  that 
the  compression  of  the  vessel  stops  the  pulsation  in  the  aneu- 
rismal  tumor. 

Should  there  be  two  vessels,  and  that  the  compression  of 
both  be  found  necessary  to  cause  the  pulsation  of  the  sac  to 
cease,  hoth  of  them  should  be  tied. 

If  the  operation  be  performed  in  the  inferior  third  of  the 
arm,  the  surgeon  will  meet  with  the  internal  cutaneous  nerve 
and  basilic  vein  in  his  first  incisions;  and  after  having  cut 
through  the  brachial  aponeurosis  he  will  look  for  the  biceps 
tendon,  the  inner  edge  of  which  will  be  his  guide  to  the 
artery  in  this  situation  :  the  median  nerve  will  be  found  still 
more  internally,  lying  at  the  inner  side  of  the  artery. 

Ligature  of  the  Brachial  Artery  at  the  bend  of  the  elbow. 
The  elbow-joint  being  extended,  the  hand  supinated,  an  in- 
cision may  be  made,  commencing  at  the  internal  margin  of 
the  median  basilic  vein,  about  an  inch  above  the  internal 


LIGATURE   OF   THE   BRACHIAL   ARTERY.  215 

condyle,  and  carried  downwards  and  a  little  outwards  for 
above  two  inches  and  a  half,  along  the  radial  margin  of  the 
pronator  radii  teres  muscle.  The  vein  and  external  lip  of  the 
wound  being  drawn  outwards,  the  fascia  and  semilunar  pro- 
cess of  the  biceps  tendon  may  be  successively  divided  on  a 
director.  At  the  bottom  of  the  wound  will  be  found  the 
biceps  tendon  externally,  the  median  nerve  internally,  and  the 
artery  between  both  and  a  little  behind  them.  The  needle 
may  then  be  passed  behind  the  artery  from  within  outwards. 
Several  small  branches  of  the  internal  cutaneous  nerve  are 
necessarily  divided  in  this  operation.  The  superficial  veins 
should  be  carefully  kept  out  of  the  way;  if  one  of  them, 
however,  should  unavoidably  interfere  with  the  operation, 
Yelpeau  advises  to  "cut  it  between  two  ligatures,  or  even 
without  this  precaution,  if  not  very  large.'' 

If  the  operation  be  performed  for  a  wound  in  the  artery 
accompanied  with  an  extravasation  of  arterial  blood,  we  should 
cut  through  the  sac  and  turn  out  the  coagulated  blood :  the 
surgeon  will  be  obliged,  generally  speaking,  to  relax  the 
tourniquet  in  order  to  ascertain  the  situation  of  the  orifice  in 
the  bleeding  vessel,  and  by  the  introduction  of  a  probe  in  the 
opening  he  will  be  able  still  more  clearly  to  discover  its  pre- 
cise situation  and  extent.  Having  raised  the  artery  from  its 
bed  and  separated  it  from  the  median  nerve,  a  double  ligature 
should  be  passed  beneath  it:  this  ligature  should  be  after- 
wards divided  into  its  two  separate  portions,  and  the  artery 
secured  above  and  below  the  wound.  This  is  the  treatment 
which  Scarpa  recommends  for  difiiise  aneurism  following  a 
wound  of  the  brachial  artery. 

The  surgeon  would,  however,  do  well  to  remember  that 
where  there  has  been  a  considerable  extravasation  of  blood 
as  the  result  of  the  wound  of  the  artery,  into  the  areolar 
tissue  of  the  limb,  the  relative  position  of  the  parts  will  be 
greatly  altered  from  that  which  we  have  just  described.  The 
entire  of  the  bend  of  the  elbow  may  be  found  filled  with  coagu- 


216  BRANCHES  OF  THE  BRACHIAL. 

lated  blood  and  enormously  distended,  so  that  in  order  to  obtain 
a  view  of  the  tendon  or  of  the  nerve  or  artery,  it  will  be  essen- 
tlally  necessary  to  turn  out  completely  the  coagula,  and  then 
only  can  he  expect  to  discover  the  bleeding  vessel. 

The  branches  of  the  brachial  artery  as  it  passes  along  the 
arm  are  the  following: — 

Superior  Profunda.  Inferior  Profunda. 

Arteria  Nutritia.  Anastomotic. 

Muscular. 

The  Superior  profunda  artery  arises  a  little  beneath  the 
conjoined  tendons  of  the  teres  major  and  latissimus  dorsi 
muscles,  and  then  sinks,  in  company  with  the  musculo-spiral 
nerve,  into  a  canal  formed  by  the  three  heads  of  the  triceps 
muscle  and  the  bone.  From  the  back  of  the  humerus  it 
winds  round  to  its  outside  in  a  spiral  groove,  which  may  be 
observed  on  that  bone  beneath  the  insertion  of  the  deltoid 
muscle :  here  it  divides  into  two  branches,  an  anterior  and 
posterior.  The  anterior  pierces  the  external  intermuscular 
ligament,  and,  accompanied  by  the  musculo-spiral  nerve, 
descends  in  a  groove  between  the  brachialis  anticus  and  supi- 
nator longus  muscles,  to  anastomose  with  the  anterior  radial 
recurrent  artery.  In  this  groove  it  is  covered  by  the  external 
cutaneous  and  musculo-spiral  nerves,  and  still  more  super- 
ficially by  the  cephalic  vein.  The  posterior  branch  descends 
in  the  substance  of  the  triceps  muscle,  to  which  it  sends 
numerous  small  branches,  and  terminates  in  anastomosing 
with  the  anterior  branch  and  with  the  posterior  interosseal 
and  ulnar  recurrents.  The  superior  profunda  artery  is  often 
very  large,  particularly  when  it  arises  from  the  posterior  cir- 
cumflex. 

The  Arteria  Nutritia,  or  nutritious  artei'y  of  the  humerus, 
arises  high  up  from  the  brachial,  below  the  superior  profunda, 
and  penetrates  the  oblique  canal  that  may  be  observed  on  the 
inside  of  the  humerus,  taking  the  direction  downwards  through 


BRANCHES  OP  THE  BRACHIAL.  217 

the  compact  tissue  of  the  bone,  towards  the  elbow-joint.  It 
supplies  the  medullary  membrane  and  cancellated  structure  of 
the  bone,  and  anastomoses  with  its  other  nutritious  arteries, 
which  are  much  smaller,  and  enter  at  various  points,  particu- 
larly near  the  extremities.  Professor  Harrison  relates  a  case 
in  which  an  aneurism  of  this  artery  ensued  on  a  fracture  of 
the  humerus,  and  amputation  was  deemed  necessary.* 

The  Inferior  profunda  artery  arises  nearly  opposite  the 
insertion  of  the  coraco-brachialis  muscle,  and  descends  on  the 
outside  of  the  ulnar  nerve,  pierces  with  it  the  internal  inter- 
muscular ligament,  and  descends  between  this  ligament  and 
the  triceps  muscle  to  the  interval  between  the  internal  con- 
dyle of  the  humerus  and  the  olecranon  process  of  the  ulna, 
where  it  is  covered  by  the  ulnar  nerve,  and  anastomoses  with 
the  posterior  ulnar  recurrent  artery,  and  with  branches  from 
the  anastomotic  artery.  In  this  course  it  supplies  the  integu- 
ments of  the  arm,  and  the  biceps  and  triceps  muscles.  This 
artery  may  be  small,  absent,  or  double,  or  may  arise  in  com- 
mon with  the  superior  profunda. 

The  Anastomotic  artery  arises  from  the  inside  of  the 
brachial,  a  little  above  the  bend  of  the  elbow ;  it  then  descends 
with  a  slight  degree  of  obliquity  inwards,  anastomoses  with 
the  anterior  ulnar  recurrent,  pierces  the  internal  intermus- 
cular ligament,  and  terminates  between  the  internal  condyle  and 
olecranon  process,  in  anastomosing  with  the  inferior  profunda 
artery  and  the  posterior  ulnar  recurrent.  The  anastomotic 
artery  varies  considerably  in  size,  being  usually  small,  but 
sometimes  as  large  as  the  inferior  profunda. 

The  Muscular  branches  are  distributed  in  all  directions: 
some  go  forwards  to  the  biceps  muscle,  others  backwards  to 
the  brachialis  anticus ;  a  third  set  are  distributed  externally 
to  the  coraco-brachialis  muscle ;  and  a  fourth  internally,  ex- 
tend to  the  pectoral  muscles. 


*  Surgical  Anatomy  of  the  Arteries,  p.  180. 
19 


218  ULNAR   ARTERY. 

At  the  bend  of  the  elbow,  the  brachial  artery  divides  into 
two  terminating  branches.  Professor  Harrison  refers  this 
division  to  a  point  opposite  to  the  coronoid  process  of  the 
ulna;  and  Professor  Quain  states  that  the  usual  place  is  a 
little  below  the  elbow-joint. 

The  terminating  branches  are  the  following  : — 

Ulnar  Artery.  Radial  Artery. 

The  Ulnar  Artery,  larger  than  the  radial,  proceeds  at 
first  obliquely  downwards  and  inwards  beneath  the  pronator 
radii  teres  muscle,  the  deep  head  of  which  separates  it  from 
the  median  nerve;  then,  beneath  the  flexor  carpi  radialis, 
palmaris  longus,  and  flexor  sublimis  digitorum  muscles.  In 
this  course  it  lies  on  the  flexor  profundus,  and  is  usually 
accompanied  by  a  filament  of  communication  between  the 
median  and  the  ulnar  nerves.  In  the  remainder  of  its  course 
to  the  annular  ligament  of  the  carpus,  it  descends  vertically 
on  the  flexor  profundus  muscle,  covered  by  the  flexor  carpi 
ulnaris  and  flexor  sublimis,  and  may  be  exposed  by  dividing 
the  fascia  and  separating  these  two  last-mentioned  muscles: 
as  it  approaches  the  wrist-joint  it  is  placed  between  the  ten- 
don of  the  flexor  sublimis  on  its  radial  side,  and  the  flexor 
carpi  ulnaris  on  its  ulnar  side.  It  is  joined  at  an  acute  angle 
by  the  ulnar  nerve  at  the  junction  of  the  superior  and  middle 
thirds  of  the  fore-arm,  after  which  it  has  this  nerve  to  its  ulnar 
side  as  far  down  as  the  wrist-joint.  Finally  it  gets  into  the 
palm  of  the  hand  by  descending  in  front  of  the  annular  liga- 
ment, covered,  however,  by  an  aponeurotic  slip,  connecting 
the  front  of  that  ligament  to  the  pisiform  bone.  In  this  situa- 
tion the  nerve  lies  a  little  posterior  to  the  artery. 

The  ulnar  artery  gives  ofi"  the  following  branches : — 

Anterior  Ulnar  Recurrent.         Anterior  Carpal. 

Posterior  Ulnar  Recurrent.         Posterior  Carpal. 

Common  Interosseal.  Communicating   Branch  or 

Muscular  Branches.  Communicans  Profunda. 

Superficial  Palmar. 


BRANCHES  OP  THE  ULNAR.  219 

The  Anterior  Ulnar  recurrent  is  small,  and  sometimes, 
together  with  the  posterior  ulnar  recurrent,  comes  from  a 
single  trunk  common  to  them  both ;  it  passes  obliquely  down- 
wards and  inwards  in  the  first  instance  between  the  pronator 
teres  and  brachialis  anticus  muscles,  and  then,  curving  up- 
wards, gains  the  front  of  the  internal  condyle,  and  anasto- 
moses with  the  anastomotic  branch  of  the  brachial  artery. 
In  this  course  it  supplies  the  brachialis  anticus,  pronator  teres, 
flexor  carpi  radialis,  and  flexor  sublimis  muscles. 

The  Posterior  Ulnar  recurrent,  much  larger  than  the  pre- 
ceding, descends  at  first  a  little  inwards,  between  the  flexor 
profundus  digitorum,  which  lies  behind  it,  and  the  muscles 
arising  from  the  internal  condyle,  which  lie  in  front.  It  then 
ascends  parallel  to  the  ulnar  nerve  and  between  the  heads  of 
the  flexor  carpi  ulnaris,  to  arrive  at  the  interval  between  the 
internal  condyle  and  olecranon  process;  here  it  terminates  in 
communicating  with  the  anastomotic  and  inferior  profunda 
branch  of  the  brachial,  having  previously  supplied  the  above- 
mentioned  muscles,  besides  the  elbow-joint,  ulnar  nerve  and 
integuments.  The  superior  radio-ulnar  articulation  is  sup- 
plied by  a  small  artery,  arteria  articularis  cuhiti  mediae 
which,  according  to  Meyer,  arises  from  the  brachial,  ulnar,  or 
interosseal  artery;  this  small  artery  passes  into  the  joint  and 
supplies  the  synovial  membrane ;  he  says  it  is  analogous  to 
the  posterior  articular  artery  of  the  knee-joint. 

The  Common  Interosseal  artery  comes  off  immediately 
below  the  recurrents,  and  descends  backwards  and  outwards 
to  the  superior  margin  of  the  interosseous  ligament,  where  it 
divides  into  the  anterior  and  posterior  interosseal  arteries. 
Before  its  division  it  gives  off  a  small  but  pretty  constant 
artery,  the  comes  nervi  mediani,  which  accompanies  the 
median  nerve  to  the  wrist,  where  it  terminates :  occasionally 
this  artery  is  of  considerable  size,  and  joins  the  superficial 
palmar  arch:  it  is  sometimes  a  branch  of  the  ulnar.  The 
Anterior  interosseal  artery  descends  on  the  front  of  the  inter- 


220  INTEROSSEAL   ARTERY. 

osseous  ligament,  between  the  flexor  pollicis  longus  and  flexor 
digitorum  profundus  muscles,  being  covered  and  accompanied 
down  the  fore-arm  by  a  branch  of  the  median  nerve ;  in  its 
course  down  the  fore-arm  it  sends  small  branches  to  the  mus- 
cles in  relation  to  it,  and  two  or  three  very  small  perforating 
arteries  which  pass  through  the  interosseous  ligament  and 
supply  the  deep-seated  muscles  on  the  back  of  the  fore-arm. 
Having  arrived  at  the  pronator  quadratus  muscle,  the  anterior 
interosseal  divides  into  two  branches :  one  supplies  this  mus- 
cle, and  terminates  in  anastomosing  with  the  carpal  arteries 
and  the  deep  palmar  arch;  the  other  passes  backwards 
through  an  oval  opening  in  the  lower  portion  of  the  inter- 
osseous ligament,  to  anastomose  with  the  posterior  carpal  and 
posterior  interosseal  arteries.  The  Posterior  interosseal 
artery  passes  downwards  and  backwards,  between  the  anterior 
oblique  and  interosseous  ligaments,  and,  having  thus  arrived 
at  the  posterior  superior  part  of  the  fore-arm,  gives  off  the 
interosseal  recurrent  branch,  improperly  called  the  ^^ posterior 
radial  recurrent  artery, ''  which  ascends  between  the  supinator 
brevis  and  anconeus  muscles,  and  then  through  the  fossa 
between  the  external  condyle  of  the  humerus  and  the  olecra- 
non process :  after  piercing  the  triceps  muscle  it  terminates 
in  anastomosing  with  the  superior  profunda  and  posterior 
ulnar  recurrent  arteries.  After  giving  off  this  recurrent 
branch,  the  posterior  interosseal  artery  descends  on  the  back 
of  the  fore-arm,  not  lying  on  the  interosseous  ligament,  but 
placed  between  the  superficial  and  deep  layer  of  muscles.  In 
this  course  it  is  accompanied  by  a  branch  of  the  musculo- 
spiral  nerve,  and  gives  off  numerous  branches  to  the  surround- 
ing muscles  ',  at  the  wrist  the  artery  becomes  very  small,  and 
terminates  in  anastomosing  with  the  anterior  interosseal  and 
the  posterior  carpal  arteries. 

The  Muscular  branches  pass  off  from  the  ulnar  artery  in  its 
course  along  the  fore-arm,  and  supply  the  various  muscles 
with  which  it  is  related. 


COMMUNICANS   PROFUNDA.  221 

The  Anterior  carpal  branch,  extremely  small,  passes  hori- 
zontally outwards,  along  the  inferior  margin  of  the  pronator 
quadratus  muscle,  and  behind  the  tendons  of  the  superficial 
and  deep  flexors.  It  anastomoses  with  the  anterior  carpal 
branch  of  the  radial  artery. 

The  Posterior  carpal  branch  comes  off  about  an  inch  and 
a  half  above  the  pisiform  bone :  it  winds  round  the  inferior 
extremity  of  the  ulna  to  the  back  of  the  carpus,  in  passing 
beneath  the  tendon  of  the  flexor  ulnaris  muscle :  it  sends 
small  branches  to  the  little  finger,  and  terminates  by  anasto- 
mosing with  the  posterior  carpal  branch  of  the  radial 

After  the  ulnar  artery  has  arrived  in  the  palm  of  the 
hand,  it  terminates  by  dividing  into  the  communieans  pro- 
funda and  palmaris  superficialis  branches. 

The  Communieans  profunda  should  not  be  dissected  till 
the  palmaris  superficialis  and  superficial  palmar  arch  of  arte- 
ries have  been  examined.  It  passes  obliquely  downwards  and 
inwards,  between  the  pisiform  bone  and  unciform  process  of 
the  unciform  bone,  lying  superficial  to  the  ligament  which 
connects  these  bones;  it  next  passes  between  the  origin  of 
the  abductor  minimi  digiti  internally,  and  the  origin  of  the 
flexor  minimi  digiti  externally;  it  then  turns  outwards,  be- 
neath the  two  muscles  arising  from  the  unciform  process,  viz., 
the  short  flexor  and  opponens  minimi  digiti,  to  join  the 
palmaris  profunda,  a  branch  of  the  radial,  and  so  to  form  the 
deep  palmar  arch.  In  this  course  it  is  accompanied  by  a 
large  branch  of  the  ulnar  nerve  which  lies  superficial  to  it. 

The  Superficial  palmar  artery  is  usually  much  larger  than 
the  preceding.  It  winds  downwards  and  outwards,  beneath 
the  palmar  aponeurosis,  to  inosculate  with  the  superficialis 
volae,  a  branch  of  the  radial  artery;  and  thus  forms  the  su- 
perficial palmar  arch. 

SUPERFICIAL   PALMAR  ARCH. 
The    Superficial   palmar   arch   of   arteries    corresponds 

19* 


222  DIGITAL   ARTERIES. 

nearly  to  the  semicircular  fold  on  the  palm  of  the  hand 
which  circumscribes  the  muscles  of  the  thumb:  it  is,  in 
general,  smaller  than  the  deep  arch,  and  its  convexity,  which 
looks  downwards  and  inwards,  is  nearer  to  the  phalanges: 
anteriorly  it  is  covered  by  the  integuments  and  palmar 
aponeurosis :  posteriorly  it  lies  on  the  flexor  tendons,  and  the 
divisions  of  the  median  nerve  as  they  pass  to  the  fingers.  In 
the  fore-arm  we  see  the  radial  and  ulnar  arteries  lying  be- 
tween their  corresponding  nerves;  but  in  the  hand  the  order 
is  reversed,  the  nerves  being  situated  between  the  arches  of 
arteries. 

The  branches  of  the  superficial  palmar  arch  arise  both 
from  its  concavity  and  from  its  convexity. 

The  Branches  from  the  Concavity  of  the  Superficial  Palmar 
Arch  are  small  and  numerous :  they  supply  the  tendons  of 
the  flexor  muscles,  the  lumbricales,  lower  portion  of  the 
median  nerve,  the  annular  ligament,  and  parts  in  the  imme- 
diate vicinity ;  and  anastomose  with  branches  of  the  radial 
and  ulnar  arteries. 

The  Branches  from  the  Convexity  of  the  Superficial  Palmar 
Arch  are  the  four  digital  arteries. 

The  First  Digital  artery ^  or  the  most  internal,  supplies  the 
ulnar  side  of  the  little  finger;  the  second  advances  to  the 
cleft  between  the  little  and  ring  fingers;  the  third  to  the 
cleft  between  the  middle  and  ring  fingers;  and  the  fourth  to 
the  cleft  between  the  middle  and  index  fingers :  each  of  them 
then  bifurcates  to  supply  the  opposed  surfaces  of  the  respect- 
ive fingers.  These  digital  arteries  follow  the  anterior  and 
lateral  margins  of  the  fingers,  supplying  the  digital  articula- 
tions and  synovial  sheaths,  and  forming  a  vascular  plexus 
beneath  the  nail  of  each  finger.  Those  of  the  same  finger 
frequently  communicate  both  in  its  anterior  and  posterior 
regions,  and  opposite  the  ungual  phalanx  meet  in  the  form 
of  an  arch,  the  concavity  of  which  looks  towards  the  hand, 
and   from   the   convexity  of  which   are  sent  ofi"  numerous 


LIGATURE    OF   THE    ULNAR   ARTERY.  223 

minute  vessels  to  supply  the  exfremities  of  the  fingers.  The 
digital  nerves  are  superficial,  that  is,  anterior  to  the  arteries ; 
the  latter  either  pierce  or  cross  the  nerves  in  order  to  obtain 
this  position. 

It  is  of  importance  to  know  the  precise  spot  at  which  the 
bifurcation  of  the  second,  third,  and  fourth  digital  arteries 
takes  place,  in  order  that  the  surgeon  may  avoid  wounding 
these  arteries  when  making  the  necessary  incisions  into  the 
palm  of  the  hand,  for  the  purpose  of  giving  exit  to  matter  in 
its  locality.  If  we  examine  the  palm  of  the  hand,  we  will 
find  a  fold  or  crease  running  somewhat  transversely  from  one 
side  to  the  other,  and  corresponding  to  the  palmar  surface  of 
the  metacarpo-phalangeal  articulations  of  the  four  fingers. 
If  we  measure  from  this  fold  forwards  to  the  lunated  margin 
of  each  of  the  three  webs  between  the  fingers,  we  will  find 
the  distance  of  each  to  be  from  about  an  inch  and  a  quarter 
to  an  inch  and  a  half:  the  bifurcation  of  each  of  the  digital 
arteries  will  be  found  to  correspond  to  about  the  central 
point  between  the  fold  and  the  anterior  or  lunated  border  of 
the  web. 

Operation  of  tying  the  Ulnar  Artery.  -^If  the  ulnar  artery 
be  wounded  in  its  superior  third,  we  may  either  adopt  the 
method  recommended  by  Mr.  Guthrie,  and  cut  down  through 
the  mass  of  muscles  which  covers  it,  taking  care  to  avoid  the 
median  nerve ;  or  we  may  tie  the  brachial  artery  in  its  in- 
ferior third :  the  latter  proceeding,  in  conjunction  with  the 
employment  of  graduated  compresses  and  bandages  to  the 
part  of  the  limb  below  this,  is  to  be  preferred.  If  the  upper 
part  of  the  ulnar  artery  be  afi"ected  with  aneurism,  tying  the 
brachial  is  the  only  proper  course.  If  it  be  necessary  to  tie 
the  ulnar  artery  lower  down,  as  in  cases  of  wounds,  it  will  be 
readily  found  by  cutting  on  the  interval  between  the  flexor 
subUmis  digitorum  and  flexor  carpi  ulnaris.  The  fascia 
should  be  divided  on  a  director,  and  the  needle  carried  round 


224  RADIAL   ARTERY. 

the  vessel  from  within  outwards,  taking  care  to  avoid  the 
nerve  which  lies  to  its  ulnar  side,  and  the  venae  comites  which 
lie  one  on  either  side. 

AVounds  of  the  palmar  arch  generally  bleed  profusely. 
If  a  spouting  vessel  present  itself,  it  may  be  seized  with 
the  tenaculum,  and  secured  in  a  ligature.  This  practice, 
however,  is  seldom  available,  as  the  blood  generally  flows 
from  a  number  of  orifices,  which  are  by  no  means  distinct. 
In  such  case  the  surgeon  should  close  the  wound,  and  employ 
a  bandage  with  graduated  compresses ;  or,  if  this  should  fail, 
he  may  introduce  into  it  a  bit  of  sponge,  covered  with  gauze 
to  prevent  the  lymph  efi'used  from  lodging  in  its  cells,  and 
then  apply  the  bandage  and  compresses  as  before:  this,  with 
the  temporary  application  of  the  tourniquet  to  the  brachial 
artery,  or  the  application  of  compresses  placed  on  the  ulnar 
and  radial  arteries,  will  usually  be  sufficient  even  in  severe 
cases.  Sometimes,  however,  it  may  be  necessary  to  tie  one  or 
both  arteries  of  the  fore-arm  :  even  after  this  the  hemorrhage 
has  continued,  and  in  an  instance  of  the  kind,  Mr.  Adams 
has  succeeded  in  restraining  the  bleeding  by  the  application 
of  a  compress  and  bandage  over  the  back  of  the  wrist,  so  as 
to  exercise  pressure  on  the  dorsal  carpal  arteries.  If  the 
wound  be  towards  the  radial  side,  we  should  tie  the  radial 
first ;  and  if  on  the  ulnar  side,  the  ulnar  artery  should  be  first 
secured.  It  should  be  recollected  that  sometimes  the  artery 
accompanying  the  median  nerve,  and  the  anterior  interosseal 
artery,  are  particularly  large,  and  terminate  in  the  superficial 
or  deep  arch. 

The  Radial  Artery,  smaller  than  the  ulnar,  but  more 
in  the  direction  of  the  brachial  artery,  descends  towards  the 
wrist,  being  related  posteriorly,  from  above  downwards,  to  the 
tendon  of  the  biceps,  the  insertion  of  the  supinator  brevis, 
the  pronator  teres,  the  radial  origin  of  the  flexor  sublimis, 
the  flexor  pollicis  longus,  and  the  pronator  quadratus  muscles : 


RADIAL   ARTERY. 


225 


f 


externalli/,  it  is  related  to  the  supinator  longus  muscle,  which 
overlaps  it  a  little ;  and  internally  to  the  pronator  teres  above, 
and  flexor  carpi  radialis  lower  down.  Anteriorly  it  is  covered 
only  by  fascia,  integuments,  and  the 
approximation  of  the  muscles  at  either 
side.  Thus  in  the  upper  part  of  its 
course  the  artery  will  be  found  be- 
tween the  supinator  longus  and  pro- 
nator teres,  whilst  below  this  it  lies 
between  the  supinator  radii  longus 
and  flexor  carpi  radialis.  The  radial 
artery  is  accompanied  by  two  veins, 
the  ven-x  comites,  and  in  the  two 
superior  thirds  of  the  fore-arm  by 
the  radial  branch  of  the  musculo- 
spiral  nerve,  which  lies  to  its  outer 
or  radial  side :  below  this  point  the 
nerve  forsakes  the  artery  and  winds 
round    the    outside    of    the    radius. 


Fig.  29. — Represents  the  Deep  Arteries  of  the  upper 
Extremity, 

A,  A,  Brachial  Artery.  B,  B,  Radial  Artery.  C,  C,  Ulnar 
Artery.  D,  D,  Anterior  Interosseal  Artery.  K,  Slender  twig 
to  the  Brachialis  Anticus.  P,  Deep  Palmar  aich  of  Arteries 
formed  by  the  Communicans  Profunda  of  the  Ulnar,  and 
Palmaris  Profunda  of  the  Radial  Arteries.  Q,  Portion  of 
First  Dorsal  Interosseous  Muscle.  1,  Coraco-brachialis  Muscle. 
2,  Long  portion  of  Triceps  Muscle.  3,  Brachialis  Anticus. 
4,  Internal  Intermuscular  Septum.  5,  Short  portion  of 
Triceps  Muscle.  6,  Extensor  Carpi  Radialis  Longus.  7,  Twig 
to  the  Brachialis  Anticus.  8,  Part  of  the  origin  of  Pronator 
Radii  Teres.  9,  Origins  of  Flexor  Carpi  Radialis  and  Palma- 
ris Longus.  10,  Extensor  Carpi  Radialis  Brevis  Muscle.  11, 
Supinator  Radii  Brevis  Muscle.  12,  Portion  of  the  Plexor 
Profundus  Muscle.  13.  Insertion  of  Pronator  Teres  cut.  14, 
15,  Flexor  PoUicis  Longus  having  the  Radial  Artery  passing 
over  it.  16,  16,  16.  The  Interosseous  Ligament  with  Anterior 
Interosseal  Artery.  17.  Pronator  Quadratus  with  branch  of 
Interosseal  Artery.  18,  Anastomosis  between  Anterior  Inter- 
osseal, the  Deep  Palmar  Arch,  and  the  Anterior  Carpal 
Arteries.  19,  20,  Abductor  Minimi  Digit!  Muscle.  21.  1,  Jl, 
Palmar  Interossei  Muscles,  a,  Muscular  Branch,  c,  Superior 
Profunda  Artery,  d,  Inferior  Profunda  Artery,  e,  f.  g,  h, 
Muscular  branches  to  Triceps  and  Brachialis  Anticus  Muscles. 
i.  Anastomotic  Artery.  1,  Radial  Recurrent  Artery,  m, 
SuperBcialis  Vola;  cut.  n,  Princeps  Pollicis  Arteiy.  o,  Ante- 
rior Ulnar  Recurrent  Artery  ascending  to  anastomose  with 
the  Anastomotic  artery,  r,  r,  r.  Digital  Arteries,  s,  s,  «i.  Cut 
ends  of  the  Digital  Arteries  of  the  Superficial  Palmar  Arch, 
t,  t,  t,  t,  u,  u,  u,  u,  V,  V,  V,  V,  Anastomoses  between  the  Digi- 
tal Arteries. 


226 


RADIAL   ARTERY. 


passing  underncatli  the  tendon  of  the  supinator  radii  longus, 
in  order  to  arrive  at  the  outer  side  of  the  posterior  part  of  the 
fore-arm.  At  the  lower  extremity  of  the  fore-arm  the  artery 
turns  round  the  external  lateral  ligament  of  the  wrist-joint, 
being  parallel  to  the  radial  extensor  muscles,  and  covered 
?"/  -'^  by  the  extensor  muscles  of  the  thumb. 

Here  it  pierces  the  abductor  indicis 
manus  muscle,  and  terminates,  in 
crossing  the  palm  of  the  hand,  under 
the  name  of  the  palmaris  profunda. 
As  the  artery  is  passing  obliquely 
across  the  back  of  the  outer  portion 
of  the  wrist,  it  will  be  found  lodged 
in  a  triangular  space,  the  base  of 
which  corresponds  to  the  back  part 
of  the  lower  extremity  of  the  radius; 
the  apex  is  situated  at  the  metacarpal 
bone  of  the  thumb;  one  side  is  formed 
by  the  extensor  secundi  internodii 
pollicis  and  extensor  carpi  radialis 
longus ;  and  the  other,  or  radial  side, 
is  formed  by  the  tendon  of  the  ex- 
tensor primi  internodii  pollicis.  Im- 
mediately underneath  the  integu- 
ments covering  this  hollow  space,  we 


Fig.  ZO.— Represents  the  arteries  of  the  posterior 
part  of  the  upper  extremity  which  are  seen  after 
the  removal  of  the  skin  and  aponeurosis. 

1,  Deltoid  Muscle.  2.  Triceps  Extensor  Cubiti.  3,  Biceps 
Flexor  Cubiti.  4,  Brachialis  Anticiis.  5,  Supinator  Longus. 
6,  Extensor  Carpi  Radialis  Longus.  7,  Extensor  Carpi  Eadialis 
Brevis.  8,  Extensor  Communis  Digitoruni.  9,  Extensor  Carpi 
Ulnaris.  10,  Anconeus  Muscle.  11,  Flexor  Carpi  Ulnaris.  12, 
Extensor  Osss  Metacarpi  Pollicis.  13,  Extensor  Prinii  Inter- 
nodii Pollicis,  a,  a.  a.  Muscular  branches  of  the  Supeiior 
Profunda,  b.  Branch  of  the  Superior  Profunda,  c,  c,  Anas- 
tomoses between  the  Superior  Profunda  and  Twigs  from  tho 
Interosseal  and  Posterior  Ulnar  Recurrent  Arteries,  d.  Twig 
from  the  Radial  Recurrent  Artery,  e,  Twigs  from  the  Inter- 
o-sscal  Artery,  f,  Twig  from  the  Interosseal  Artery,  g,  h, 
Arterial  Anastomosis,  i,  Radial  Artery,  k,  k,  k,  k.  Twigs 
from  the  Anterior  Digital  Arteries  to  the  backs  of  the  lingers. 


BRANCHES   OF   THE   RADIAL.  227 

find  the  origin  of  the  radial  vein  and  some  branches  of  the 
radial  division  of  the  musculo-spiral  nerve. 

The  branches  of  the  radial  artery  are  the  following : — 

Radial  Recurrent.  Dorsalis  Pollicis. 

Muscular.  Metacarpal. 

Superficialis  Volae.  Radialis  Indicis. 

Anterior  Carpal.  Princeps  Pollicis. 

Posterior  Carpal.  Palmaris  Profunda. 

The  Radial  recurrent.  This  branch,  which  arises  high  up 
in  the  fore-arm,  proceeds  at  first  in  a  curved  direction  out- 
wards, the  convexity  of  the  curve  looking  downwards  and 
lying  below  the  radio-humeral  articulation :  it  then  ascends 
on  the  front  of  the  supinator  brevis,  in  the  groove  between 
the  supinator  longus  and  brachialis  anticus,  where  it  anasto- 
moses with  the  superior  profunda  artery :  from  the  convexity 
of  its  arch  it  sends  many  branches  downwards  to  be  lost  in 
the  supinator  brevis  and  supinator  longus  muscles,  and  in  the 
upper  extremities  of  the  extensor  muscles. 

The  Muscular  branches.  In  its  course  down  the  fore-arm, 
the  radial  artery  sends  branches  to  the  adjacent  muscles,  and 
through  the  aponeurosis  to  the  integuments. 

The  Superficialis  Volse.  This  is  usually  a  small  branch ; 
sometimes,  however,  it  is  very  considerable.  It  descends  on 
the  front  of  the  annular  ligament  of  the  wrist ;  then  over,  or 
through  the  origins  of  the  small  muscles  belonging  to  the 
thumb.  It  next  turns  inwards,  beneath  the  palmar  aponeu- 
rosis, and,  by  anastomosing  with  the  superficial  palmar  branch 
of  the  ulnar  artery,  contributes  to  form  the  superficial  palmar 
arch  already  described. 

The  Anterior  Carpal  artery  is  small  but  constant.  It  runs 
transversely  inwards,  along  the  inferior  margin  of  the  pro- 
nator quadratus,  to  anastomose  with  a  similar  branch  from 
the  ulnar. 

The  Posterior  Carpal  artery  is  very  much  larger  than  the 


228 


BRANCHES    OF    THE    RADIAL. 


anterior.  Its  origin  corresponds  to  the  outer  edge  of  the 
extensor  carpi  radialis  longus  muscle,  and  is  nearly  opposite 
the  interval  between  the  first  and  second  range  of  carpal 
bones.  It  passes  almost  horizontally  inwards,  lying  on  the 
second  row  of  carpal  bones,  covered  by  the  radial  extensors 
and  the  extensors  of  the  fingers,  to 
anastomose  with  the  posterior  carpal 
branch  of  the  ulnar  artery;  its  superior 
branches  are  distributed  to  the  wrist- 
joint,  and  communicate  with  the  anterior 
interosseal;  its  inferior  branches  are 
the  second,  third,  and  fourth  perforating 
arteries,  each  of  which  sinks  between 
the  heads  of  the  corresponding  dorsal 
interosseous  muscle,  to  join  the  deep 
palmar  arch :  the  trunk  of  the  radial 
artery  may  be  considered  the  first  per- 
forating artery,  as  it  pierces  the  first 
interosseous  muscle,  or  abductor  indicis 
manus,  in  a  similar  manner.  Before 
these  arteries  pierce  the  muscles,  they 
send  ofi"  interosseal  branches,  which 
descend  between  the  interosseous  mus- 


Ei 


>' 


f^i 


^/ 


Fig.  31. — Represents  the  deep  arteries  of  the  posterior 
part  of  the  tipper  extremity, 

1,  Humerus.  2,  Brachlalis  Amicus.  3,  Origins  of  Supinator 
Radii  Longus  and  Extensor  Carpi  Rndialis  Longus  Muscles.  4, 
Portion  of  Insertion  of  Triceps.  5,  External  Lateral  Ligament 
of  the  Elbow-joint.  6,  6,  Interosseous  Ligament  of  the  Fore-arm. 
7,  Ulna.  8,  Radius,  a,  a,  Superior  Profunda  Artery,  b,  Radial 
Recurrent  Artery,  c,  c,  Anastomoses  between  the  Superior  Pro- 
funda, the  Radial  Recurrent,  and  Interosseal  Recurrent  Arteries, 
d.  Posterior  Interosseal  Artery,  after  passing  backwards  between 
the  Oblique  and  Interosseous  Ligaments,  divided,  e,  f,  f,  f,  g, 
Perforating  branches  from  the  Anterior  Interosseal  Artery,  h, 
•Twig  to  Carpus,  i.  Radial  Artery,  k,  k,  k,  Dorsal  Carpal  Twigs. 
1,  Dorsal  Artery  of  Thumb,  m,  Internal  Dorsal  Artery  of  Thumb, 
n,  Continuation  of  the  Princeps  PoUicis  Artery,  o,  Radialis 
Indicis  Artery,  p,  Posterior  Carpal  branch  of  Ulnar  Artery, 
q,  Branch  of  Posterior  Ulnar  Carpal  Artery  to  the  little  finger, 
r.  r,  r.  Perforating  Twigs  of  the  Palmar  Interosseal  Arteries, 
s,  s,  s.  Dorsal  or  Posterior  Interosseal  Arteries  of  hand,  t.  Radial 
Artery  passing  into  the  palm  of  the  hand,  u,  v,  w,  x,  y,  z.  Small 
branches  to  ttie  sides  of  the  Doisal  asjicct  of  the  1st,  2d,  3d,  and 
4tb  fingers. 


BRANCHES   OF   THE    RADIAL.  229 

cles  and  integuments,  and  occasionally  pierce  the  lower  part 
of  the  interosseous  space,  to  join  the  digital  branches  of 
the  palmar  arch. 

The  Dorsalis  Pollicis.  Before  the  radial  artery  sinks  be- 
tween the  two  first  metacarpal  bones,  it  gives  a  branch  or 
branches  to  the  posterior  surface  of  the  metacarpal  bone  of 
the  thumb  J  it  also  frequently  gives  off  a  slender  branch  that 
descends  on  the  cutaneous  surface  of  the  abductor  indicis 
manus. 

The  Metacarpal  artery^  or  dorsalis  indicis,  is  very  variable 
in  size,  being  sometimes  diminutive,  and  at  other  times  ex- 
tremely large.  Sometimes  it  seems  to  be  a  continuation  of 
the  radial.  It  descends  over  the  metacarpal  bone  of  the  index 
finger,  and  sinks  between  the  second  and  third  metacarpal 
bones,  to  join  the  digital  branch  of  the  superficial  palmar  arch 
that  supplies  the  adjacent  sides  of  the  index  and  middle 
fingers. 

The  Radialis  Indicis  descends  between  the  abductor  indicis 
and  adductor  pollicis  :  it  then  follows  the  external  margin  of 
the  index  finger,  and,  at  its  extremity,  anastomoses  with  the 
internal  digital  branch  of  the  same  finger. 

The  Frinceps  Pollicis,  or  digital  artery  of  the  thumb, 
descends  between  the  abductor  indicis  and  deep  head  of  the 
shorter  flexor  pollicis.  It  then  follows  the  internal  margin  of 
the  thumb,  and  anastomoses  with  the  other  small  digital  ves- 
sels which  run  along  the  dorsal  aspect  of  the  thumb. 

In  some  cases  the  radialis  indicis  and  princeps  pollicis  arise 
by  a  common  trunk,  which  descends  to  the  lower  part  of  the 
first  interosseous  space  before  it  bifurcates :  this  is  described 
as  the  regular  disposition  by  Cloquet  and  Boyer.  Professor 
Harrison  describes  the  radial  artery  as  terminating  by  dividing 
into  three  branches;  the  radialis  indicis,  princeps  pollicis, 
and  palmaris  profunda. 

The  Palmaris  Profunda,  This  is  the  proper  termination 
of  the  radial  artery ;  it  passes  horizontally  inwards,  between 

20 


230  DEEP   PALMAR    ARCH. 

the  metacarpal  bones  and  interosseous  muscles  which  are 
behind  it,  and  the  adductor  pollicis  and  flexor  tendons  which 
lie  in  front.  It  then  unites  with  the  deep  terminating  branch 
of  the  ulnar,  thus  forming  the  deep  palmar  arch. 

DEEP   PALMAR   ARCH. 

The  Deep  palmar  arch  of  arteries  is  covered  in  front  by 
all  the  nerves,  tendons,  and  muscles  of  the  palm  of  the  hand. 

Fig.  32. — Arteries  of  the  Hand;  Palmar  Surface. 


1,  Radial  Artery.  2,  Ulnar.  3,  Commuuioating  Branch  with  the  Deep  Palmar  Arch.  4,  Super- 
ficial Palmar  Arch.  5,  Superficial  Volar  Artery.  6,  Digital  Arteries  of  the  Thumb.  7,  Radial  Index 
Artery.  8,  Digital  Artery  to  the  Little  Finger.  9,  Common  Digital  Arteries,  10,  Digitals  to  the 
Fingers. 

except  by  the  interosseous  muscles,  which,  together  with  the 
metacarpal  bones,  lie  behind  it.  It  crosses  these  bones  nearly 
at  right  angles,  lying  close  to  their  carpal  extremities,  and 
forming  a  slight  curvature,  the  convexity  of  which  looks 
towards  the  phalanges.     This  arch  is  accompanied  by  a  branch 


DEEP   PALMAR   ARCH.  231 

of  the  ulnar  nerve,  which  passes  in  company  with  the  com- 
municans  profunda  branch  of  the  ulnar  artery  into  this  deep- 
seated  situation  of  the  hand :  the  nerve  lies  on  the  anterior 
surface  of  the  arch  and  terminates  in  the  muscles  of  the  thumb. 
The  deep  palmar  arch  gives  off  the  following  branches : — 

Anterior.  Superior. 

Posterior.  Inferior. 

The  anterior  branches  are  small,  and  are  lost  in  the  lumbri- 
cales  muscles. 

The  posterior  hranclies,  three  in  number,  pass  backwards 
towards  the  second,  third,  and  fourth  interosseous  spaces : 
each  of  them  penetrates  between  the  two  origins  of  the  cor- 
responding dorsal  interosseous  muscle,  to  communicate  with 
the  posterior  carpal  artery ;  these  arteries  may  therefore  be 
indifferently  considered  as  branches  of  the  last-mentioned 
artery,  or  of  the  deep  arch. 

The  superior  brandies  are  small,  and  are  lost  on  the  carpus. 

The  inferior  branches,  three  or  four  in  number,  descend 
along  the  interosseous  spaces,  and  anastomose  with  the  digital 
branches  of  the  superficial  palmar  arch. 

Operation  of  tying  the  Radial  Artery.  The  radial  artery 
may  be  tied  in  the  upper  part  of  the  fore-arm  by  making  an 
incision  over  the  interval  between  the  pronator  radii  teres  and 
supinator  longus.  In  the  lower  part  of  the  fore-arm  it  will  be 
found  between  the  flexor  carpi  radialis  and  supinator  longus. 
In  either  case,  after  making  the  incision  through  the  integu- 
ments, the  fascia  should  be  divided  on  a  director :  a  small  vein 
will  be  found  on  either  side  of  the  artery,  and  the  radial 
nerve  will  lie  on  its  external  side.  The  possibility  of  mis- 
taking the  superficialis  volae  for  the  trunk  of  the  radial  should 
be  borne  in  mind.  In  judging  of  the  strength  of  the  pulse 
at  the  wrist,  it  will  be  necessary  to  attend  to  the  deviations  in 
the  course  and  size  of  the  radial  artery. 

Sir  Philip  Crampton  succeeded  in  curing  a  circumscribed 


232 


THORACIC   AORTA. 


Fig.  SS.—TJie  TJioracic  Aorta  and  its  Branches. 


A,  Ascending  portion  of  the  Arch  of  the  Aorta.  B,  Middle  portion  of  the  Arch.  C,  Termination 
of  the  descending  portion  of  the  Arch.  I>,  Thoracic  Aorta.  K,  Arteria  Innominala,  or  Brachio- 
cephalic Artery.  P,  Right  Common  Carotid  Artery.  G,  Right  Subclavian  Artery.  H,  Left  Common 
Carotid  Artery.  I,  Left  Subclavian  Artery.  K,  K,  Inferior  Phrenic  or  DiapiiraKmatic  Arteries. 
which  in  this  case  came  abnormally  from  the  Coeliac  Axis,  a,  a,  a,  Sigmoid  or  Semilunar  Valves  of 
the  Aorta,  b,  Origin  of  the  Right  Coronary  Artery,  c.  Origin  of  the  Left  Coronary  Artery,  d.  Right 
Bronchial  Artery,  in  this  case  arising  from  the  concavity  of  the  Arch  of  the  Aorta,  e,  Left  Bron- 
chial Artery,  having  a  similar  origin,  f,  Esophageal  Arteries,  g,  g.  g.  g,  g,  g,  Left  Inferior  or 
Aortic  Intercostal  Arteries,  h.  h,  h,  h.  h,  h.  Right  Inferior  or  Aortic  Intercostal  Arteries.  1,  Tra- 
chea.   2,  Right  Brouchus.    3,  (Esophagus.    4,  4,  Portion  of  the  Diaphragm. 


THORACIC   AORTA.  233 

traumatic  aneurism  of  the  radial  artery  as  it  passes  behind 
the  wrist,  by  the  application  of  Dr.  Carte's  compressing  in- 
strument upon  the  artery  leading  to  the  tumor.* 

THE   DESCENDING   AORTA. 

This  large  vessel  is  a  continuation  of  the  arch  of  the  aorta, 
and  may  be  described  as  commencing  opposite  the  lower  part 
of  the  body  of  the  third  dorsal  vertebra,  and  terminating 
opposite  the  fourth  lumbar.  Its  commencement  and  termina- 
tion are  both  on  the  left  side  of  the  spine,  but  that  part  of  it 
which  passes  between  the  crura  of  the  diaphragm  approaches 
the  middle  line,  so  that  in  its  entire  course  it  forms  a  lateral 
curvature,  the  convexity  of  which  is  turned  to  the  right  side. 
In  this  respect  the  artery  accommodates  itself  to  the  natural 
lateral  curve  which  exists  in  the  dorsal  portion  of  the  spine, 
the  convexity  of  which  is  also  directed  towards  the  right  side ; 
in  addition  to  this,  the  artery  follows  the  curvature  of  the 
spine  in  the  antero-posterior  direction,  and  is  therefore  con- 
cave forwards  in  the  thoracic  region,  and  convex  forwards  in 
the  abdominal.  The  descending  aorta  is  divided  into  two 
portions,  viz.,  the  thoracic  aorta,  and  the  abdominal  aorta. 
We  shall  first  examine  the  thoracic,  and  then  the  abdominal 
portion. 

THE   THORACIC   AORTA. 

This  great  division  of  the  descending  aorta  may  be  said  to 
commence  opposite  the  third  dorsal  vertebra,  and  to  terminate 
in  passing  between  the  pillars  of  the  diaphragm.  As  far  as 
the  tenth  dorsal  vertebra  it  is  situated  in  a  region  called  the 
posterior  mediastinum:  this  region  approaches  somewhat  to 
the  form  of  a  prism,  and  extends  from  about  the  third  to 
the  tenth  dorsal  vertebra :  its  sides  are  formed  by  the  two 
pleurae;  its  apex  is  situated  anteriorly  and  corresponds  to  the 


*■  Dub.  Med.  Press,  vol.  xxii.  p.  61. 
20» 


234 


THORACIC   AORTA. 


back  part  of  tlie  pericardium,  and  its  base  is  formed  by  the 
bodies  of  the  vertebrae  from  the  third  to  the  tenth.  The 
direction  of  the  thoracic  aorta  is  downwards,  forwards,  and 
to  the  right  side.  Its  posterior  surface  rests  on  the  spine 
and  denii-azygos  vein,  and  usually  on  the  third,  fourth,  and 
fifth  intercostal  veins  of  the  left  side :  the  intercostal  arteries 
arise  from  this  part  of  the  vessel.  Its  anterior  surface  is 
covered  by  the  root  of  the  left  lung,  by  the  bijck  of  the  peri- 
cardium, and  lower  down  by  the 
oesophagus  with  the  vagi  nerves, 
and  by  the  decussating  muscular 
bands  which  spring  from  and  con- 
nect the  pillars  of  the  diaphragm. 
Its  left  side  is  closely  related  to  the 
left  pleura  and  lung.  Its  right  side 
is  related  remotely  to  the  right  lung 
and  pleura,  to  the  thoracic  duct  and 
vena  azygos,  and  inferiorly  it  is  re- 
lated to  the  right  crus  of  the  dia- 
phragm, from  which  it  is  separated 
by  the  vena  azygos  and  thoracic  duct. 
Along  its  right  side  superiorly  we  may 
also  observe  the  oesophagus  passing 
downwards  towards  the  stomach  :  if 
we  examine  the  relations  between  the 
oesophagus  and  aorta,  we  will  find 
that  these  tubes  run  somewhat  spi- 
rally with    regard   to   one   another: 

Fig.  ZL—The.  Aorta. 

1,  Arch  of  the  Aorta.  2,  Thoracic  Aorta.  3,  AMominal 
Aorta.  4,  Iiiiioniinate  Artery.  .5,  HiRht  common  Carotid, 
6,  Right  Subclavian.  7,  Leftcorainon  Carotid.  8,  Left  Sul)- 
clavian.  9,  Bronchial  Artery,  a  small  briiuch  of  the  Aorta, 
10,  (Esophageal  .\rteries.  11,  Intercostal  Arteries  of  the  right 
side.  12,  or  the  left  side.  13,  Phrenic  Arteries.  14,  Cojliac! 
Axis.  15,  Coronary  Artery.  16,  Splenic  Artery.  17,  Hepa- 
tic Artery.  18,  Superior  Mesenteric  Artery.  19,  Supra- 
renal Arteries.  I'O,  Spermatic  Arteries.  21,  inferior  Mesen- 
teric Artery.  22,  Luniliar  Arteries.  23,  Common  Iliac  Arteries. 
24,  Middle  Sacral  Artery,  a.  Aortic  Orifice  of  the  Dia- 
phragm, h,  Articulation  of  the  head  of  the  ribs,  c,  Anterior 
Scalene  Muscle. 


BRONCHIAL   ARTERIES.  235 

at  first  the  oesophagus  lies  upon  a  plane  posterior  to  the 
second  or  middle  portion  of  the  arch  of  the  aorta,  though  not 
in  immediate  relation  to  it;  it  then  lies  to  the  right  side 
of  the  third  portion  of  the  arch,  and  continues  its  course 
along  the  right  side  of  the  thoracic  aorta  until  it  reaches  a 
point  corresponding  to  about  the  body  of  the  seventh  dorsal 
vertebra;  the  oesophagus  here  begins  to  pass  obliquely  from 
right  to  left,  across  the  front  of  the  aorta,  and  finally  at  its 
termination  in  the  stomach  it  lies  to  the  left  side  of  this 
vessel,  and  upon  a  plane  considerably  anterior  to  it.  The 
right  and  left  splanchnic  nerves  descend  on  either  side  of  it, 
the  left  being  nearer  to  the  artery. 

The  branches  of  the  thoracic  aorta  are  the  following : — 

Pericardial.  G^sophageal. 

Bronchial.  Posterior  Mediastinal. 

Inferior  Intercostal. 

The  Pericardial  branches  are  a  few  small  and  irregjular 
arteries  which  arise  from  the  front  of  the  vessel  and  are  dis- 
tributed to  the  back  part  of  the  pericardium. 

The  BroncJiial  arteries  arise  from  the  anterior  part  of  the 
aorta;  they  are  amongst  the  most  irregular  in  the  body,  and 
can  only  be  recognized  by  their  termination  in  the  lung,  and 
not  by  their  origin,  as  they  may  arise  from  the  aorta,  the  in- 
tercostals,  the  mammary,  or  even  from  the  subclavian  arteries. 
Those  most  constantly  found  are  three  in  number ;  viz.,  one 
on  the  right  side;  and  two  on  the  left, — a  superior  and  an 
inferior. 

The  right  bronchial  artery  sometimes  comes  from  the  aorta, 
in  common  with  the  left,  or  separately :  usually,  however,  it 
is  a  branch  of  the  first  aortic  intercostal :  in  all  cases  it 
descends  on  the  back  of  the  right  bronchus,  and,  winding 
round  it,  accompanies  it  into  the  lung:  the  superior  left  bron- 
chial artery  usually  comes  from  the  aorta,  and  in  a  similar 
manner  twines  round  the  left  bronchus,  and  with  it  enters 


236  INTERCOSTAL   ARTERIES. 

the  lung :  the  left  inferior  bronchial  artery  often  arises  from 
the  aorta,  opposite  the  third  or  fourth  dorsal  vertebra,  and  is 
conducted  to  the  left  lung  by  the  left  superior  pulmonic  vein  : 
it  is  not  as  constant  as  the  two  preceding.  Arrived  at  the 
lung,  the  right  bronchial  artery  usually  divides  into  five 
branches,  and  the  left  into  four :  these  subdivide,  and  accom- 
pany the  divisions  of  the  bronchi  through  the  lung,  in  such 
a  manner,  however,  that  one  division  of  the  bronchus  has 
usually  with  it  two  or  three  arterial  branches,  which,  fre- 
quently anastomosing,  form  a  delicate  net-work  round  the  air- 
vessel.  The  bronchial  arteries  communicate  with  the  other 
blood-vessels  of  the  lung. 

Two  or  three  other  bronchial  arteries  may  arise  occasion- 
ally from  the  concavity  of  the  arch  of  the  aorta,  and  also 
repair  to  the  lung. 

The  (Esophageal  arteries,  three  to  six  in  number,  arise 
from  the  anterior  part  of  the  thoracic  aorta,  at  variable  points : 
they  are  lost  in  the  tunics  of  the  oesophagus,  and  in  anasto- 
mosing with  the  inferior  branches  of  the  inferior  thyroid  artery, 
and  with  the  oesophageal  branches  of  the  gastric  artery.  They 
are  always  very  small,  and  the  highest  of  them  occasionally 
comes  from  one  of  the  bronchial  arteries. 

The  Posterior  Mediastinal  branches  are  small  and  nume- 
rous :  they  arise  from  various  parts  of  the  thoracic  aorta,  and 
supply  the  glandular  structures  and  areolar  tissue  contained 
in  the  posterior  mediastinum. 

The  Inferior  or  Aortic  Intercostals  are  usually  from  nine  to 
ten  in  number  on  each  side,  according  as  the  superior  inter- 
costal gives  off  three  or  two  branches:  they  all  arise  from 
the  posterior  and  lateral  part  of  the  thoracic  aorta.  The 
superior  run  obliquely  upwards  and  outwards,  the  middle  less 
obliquely  outwards,  and  the  inferior  almost  transversely :  those 
of  the  right  side,  having  to  cross  the  spine,  are  necessarily 
longer  than  those  on  the  left,  and  have  additional  relations : 
from  their  origins  to  the  angles  of  the  ribs,  they  rest  on  the 


INTERCOSTAL   ARTERIES.  237 

spine  posteriorly,  and  are  covered  in  front  by  the  oesophagus, 
thoracic  duct,  vena  azygos,  sympathetic  nerve,  and  the  right 
pleura.  Those  of  the  left  side,  traced  as  far  as  the  heads  of 
the  ribs,  rest  on  a  very  small  portion  of  the  spine,  and  are 
only  covered  by  the  sympathetic  nerve  and  left  pleura. 

In  the  remainder  of  their  course,  being  exactly  alike  on 
right  and  left,  the  same  description  will  serve  for  the  inter- 
costal arteries  of  both  sides.  There  are  some  differences, 
however,  between  the  relations  of  those  above  and  those  below : 
thus,  the  superior  aortic  intercostal  communicates  with  the 
lowest  intercostal  branch  from  the  subclavian,  while  each  of 
the  others  communicates  with  the  aortic  intercostal  above  and 
below  it :  again,  those  low  down  cross  behind  the  splanchnic 
nerves  on  both  sides,  and  behind  the  demi-azygos  vein  on  the 
left  side ;  and  the  eleventh  and  twelfth  intercostals  on  either 
side  pass  behind  the  corresponding  pillar  of  the  diaphragm. 

Having  arrived  in  the  intercostal  space,  each  of  the  inter- 
costal arteries  divides  into  an  anterior  and  posterior  branch : 
the  anterior  branch,  larger  than  the  posterior,  proceeds  out- 
wards towards  the  angle  of  the  rib,  having  in  front  of  it  the 
pleura,  and  behind  it  the  anterior,  or  inferior  costo-transverse 
ligament,  and  the  external  layer  of  intercostal  muscles ;  having 
arrived  near  the  angle  of  the  rib,  it  divides  into  a  superior 
and  inferior  branch,  both  of  which  sink  between  the  two 
layers  of  intercostal  muscles :  the  inferior,  much  the  smaller, 
runs  for  a  short  distance  along  the  superior  margin  of  the  rib 
below,  and  is  then  lost  in  the  periosteum  on  its  external  sur- 
face ;  while  the  superior,  which  is  really  the  continued  ante- 
rior intercostal,  runs  forwards  between  the  two  layers  of  in- 
tercostal muscles,  lodged  in  the  groove  in  the  inferior  margin 
of  the  rib  above,  till  it  reaches  the  anterior  part  of  the 
thorax,  its  corresponding  vein  lying  above  it  and  its  nerve 
beneath  it;  here  it  descends  in  the  intercostal  space,  and  its 
mode  of  termination  depends  on  its  situation :  those  corre- 
sponding to  the  true  ribs  anastomose  with  the  internal  mam- 


238  THE   ABDOMINAL   AORTA. 

niary  artery;  those  corresponding  to  the  false  ribs  sink  into 
the  abdominal  muscles,  and,  having  supplied  them,  anasto- 
mase  with  the  mammary,  epigastric,  and  circumflexae  ilii  arte- 
ries. The  twelfth  anterior  intercostal  diflPers  somewhat  from 
the  preceding :  it  runs  downwards  and  outwards  between  the 
corresponding  crus  of  the  diaphragm  and  the  body  of  the  last 
doi'sal  vertebra;  then  along  the  inferior  margin  of  the  twelfth 
rib,  opposite  to  the  middle  of  which  it  divides  into  transverse 
and  descending  branches ;  these  are  lost  in  the  broad  muscles 
of  the  abdomen,  and  in  connnunication  with  the  lumbar  and 
circumflexae  ilii  vessels.  The  posterior  branch  of  each  inter- 
costal artery  passes  backwards,  between  the  body  of  the  cor- 
responding vertebra  on  the  inside,  and  the  inferior  costo- 
transverse ligament  on  the  outside :  in  this  situation  it  sends 
a  small  branch  through  the  lateral  foramen  of  the  spine  to 
the  tunics  of  the  spinal  marrow,  and  then  continues  its  course 
backwards  to  be  lost  in  the  spino-transverse,  longissimus  dorsi, 
and  sacro-lumbalis  muscle;  some  of  its  branches  extend  to 
the  latissimus  dorsi  and  trapezius  muscles,  and  are  lost  in  the 

THE   ABDOMINAL   AORTA. 

The  examination  of  this  vessel  may  be  deferred  till  its 
branches  have  been  dissected.  It  is  about  five  inches  and  a 
half  or  six  inches  in  length,  and  extends  from  the  aortic 
opening  in  the  diaphragm  to  the  left  side  of  the  fourth 
lumbar  vertebra,  or  to  the  cartilage  between  the  fourth  and 
fifth :  it  may,  however,  extend  to  the  fifth,  or  only  as  far  as 
the  second.  The  aortic  opening  in  the  diaphragm  is  oblique, 
and  corresponds  to  the  twelfth  dorsal  and  part  of  the  first 
lumbar  vertebraa :  its  sides  are  formed  by  the  two  crura  of 
the  diaphragm ;  antefinorly  and  super iorli/  it  is  bounded  by  a 
tendinous  arch  which  unites  the  two  crura  across  the  anterior 
aspect  of  the  artery,  and  from  the  convexity  of  which  arch 


"  LIGATURE   OF   THE   AORTA.  239 

some  of  the  short  fleshy  fibres  of  the  crura  arise )  and  ])o%- 
teriorly  by  the  anterior  common  ligament  of  the  spine,  which 
separates  the  vessel  from  the  first  lumbar  vertebra.  The 
posterior  surface  of  the  abdominal  aorta  rests  on  the  spine, 
right  crus  of  the  diaphragm,  which  here  sends  an  expansion 
in  front  of  the  lumbar  vertebrae ;  on  the  receptaculum  chyli, 
and  left  lumbar  veins  :  the  lumbar  and  middle  sacral  arteries 
arise  from  this  surface  of  the  vessel,  and  are  therefore  placed 
posterior  to  it.  The  anterior  surface  is  covered  from  above 
downwards,  first  by  the  posterior  edge  of  the  liver,  next  by 
the  union  of  the  semilunar  ganglia  to  form  the  solar  plexus ; 
by  the  aortic  plexus  of  nerves,  by  the  lesser  omentum  and 
stomach,  then  by  the  commencement  of  the  vena  portae  and 
superior  mesenteric  artery,  both  of  which  separate  it  from 
the  pancreas,  which  also  crosses  the  anterior  surface  of  the 
vessel ;  lower  down,  it  is  covered  by  the  left  renal  vein,  which 
separates  it  from  the  third  portion  of  the  duodenum;  this 
intestine  crosses  the  artery  at  a  point  corresponding  to  about 
the  third  lumbar  vertebra:  still  lower,  it  is  crossed  by  the 
transverse  mesocolon  and  mesentery,  and  inferiorly  by  a  single 
layer  of  the  peritoneum,  namely,  the  continuation  downwards 
of  the  inferior  or  descending  layer  of  the  mesentery.  Its 
left  side  corresponds  to  the  left  pillar  of  the  diaphragm  above, 
and  below  to  the  peritoneum.  Its  right  side  is  separated  from 
the  vena  cava  superiorly  by  the  Spigelian  lobe  of  the  liver, 
the  right  crus  of  the  diaphragm,  the  vena  azygos,  and  the 
thoracic  duct;  lower  down  it  is  nearly  in  contact  with  the 
latter  vein.  The  sympathetic  nerves  also  lie  one  at  each 
side  of  the  aorta,  the  left  being  in  closer  relation  to  it,  and 
both  on  a  plane  posterior  to  the  vessel. 

Operation  of  tying  the  Aorta. — The  abdominal  aorta  has 
been  tied  five  times  in  the  human  subject,  but  unfortunately 
in  every  case  without  success.     Sir  A.  Cooper  was  led,  by  a 


240  LIGATURE    OF    THE    AORTA.  -i 

number  of  experiments*  which  he  performed  on  dogs,  and  by 
a  consideration  of  the  various  cases  on  record,  in  which  the 
aorta  had  been  found  obliterated  after  death,  to  believe  in  the 
possibility  of  tying  this  vessel,  in  the  human  subject,  with 
safety  and  advantage.  It  is  true  that  in  every  instance  in 
which  it  was  found  impervious  in  the  human  subject,  the 
eiFect  was  produced  slowly,  and  the  anastomosing  branches 
were  gradually  prepared  for  the  additional  duty  they  were  to 
perform ;  yet  it  does  not  appear,  either  from  experiments  on 
brutes,  from  which,  however,  conclusions  should  be  drawn 
with  great  caution,  or  from  the  results  of  the  cases  in  which 
it  has  been  tied  in  man,  that  the  operation  must  fail,  either 
on  account  of  the  immediate  shock  given  to  the  system,  or 
of  the  diminished  supply  of  blood  sent  to  both  the  lower 
extremities 

Sir  A.  Cooper  says  he  has  ascertained  that  if  the  aortic 
plexus  be  tied  with  the  artery,  the  lower  extremities  are  rendered 
paralytic  and  the  animal  dies ;  but  these  consequences  do  not 
occur  if  the  plexus  be  not  included  in  the  ligature. 

LIGATURE    OP    THE    AORTA. 


No. 

Operator. 

Date  of 
Operation. 

Results  and  Observations. 

1 

2 

3 
4 

5 

Cooper 

James 

Murray 

Monteiro 

South 

1817 
1829 

1834 
1842 

1856 

Death  on  2d  day  after  the  operation. 
Death  on  the  evening  of  the  day  on  which 

the  operation  was  performed. 
Death  in  twenty-three  hours. 
Death,  from  hemorrhage,  on  10th  day  after 

operation. 
Death  in  forty-two  hours. 

Sir  A.  Cooper's  Case. — A  patient  in  Guy's  Hospital  had 
violent  bleeding  just  above  the  left  groin,  from  an  aneurismal 
tumor  of  the  external  iliac  artery.  The  integuments  had 
sloughed,  and  the  patient  was  exceedingly  reduced  from  loss 

*  Med.  Oh.  Trans.,  vol.  ii.  p.  158. 


MR.  James's  case.  241 

of  blood.  Under  these  circumstances,  and  finding  it  impos- 
sible from  the  size  of  the  tumor  to  secure  the  iliac  artery, 
Sir  A.  Cooper  felt  justified  in  tying  the  aorta.  The  opera- 
tion was  performed  in  April,  1817.  He  made  an  incision 
into  the  linea  alba  three  inches  long,  allowing  a  curve  in  it 
to  avoid  the  umbilicus.  In  this  manner  the  sac  of  the  peri- 
toneum was  opened,  and  the  fingers  were  then  conveyed  to 
the  artery,  which  was  readily  distinguished  by  its  strong  pul- 
sations. The  peritoneum  was  then  lacerated  with  the  finger- 
nail, in  order  to  allow  the  ligature  to  be  conveyed  around  it 
at  about  three-quarters  of  an  inch  above  its  bifurcation. 
During  the  operation  the  faeces  were  involuntarily  discharged. 
The  patient  died  on  the  second  day  after  the  operation,  and 
his  death  is  ascribed  by  Sir  A.  Cooper  to  want  of  circulation 
in  the  aneurismal  limb ;  which  led  him  to  observe  that  "  in 
an  aneurism  similarly  situated,  the  ligature  must  be  applied 
before  the  swelling  has  acquired  any  very  considerable  magni- 
tude."* In  his  Surgical  Lectures  he  observes,  "If  I  were 
to  perform  this  operation  again,  the  only  difi'erence  that  I 
would  make  would  be  to  cut  the  ligature  close  to  the  vessel, 
where  it  might  take  its  chance  either  to  be  encysted  or 
absorbed."  A  little  farther  on  he  observes,  "The  principal 
danger  appeared  to  arise  from  the  irritation  produced  in  the 
intestines  by  the  ligature;  and  that  is  the  reason  why  I 
would  cut  the  ligature  close  to  the  vessel."  In  dissection 
there  were  no  appearances  of  peritoneal  inflammation. 

Mr.  Jameses  Case. — "The  patient,  set.  44,  of  spare  habit, 
but  not  otherwise  unhealthy,  had  an  aneurism  of  the  external 
iliac  artery,  of  such  extent  as  to  prevent  any  chance  of  success 
from  tying  the  iliac  artery  above  the  tumor.  It  was  accord- 
ingly determined  to  tie  the  femoral  artery  on  the  distal  side 
of  the  aneurism,  according  to  Brasdor's  plan.  This  opera- 
tion was  performed  on  June  2,  1829.     The  patient  appeared 


*  Surgical  Essays,  vol.  i.  p.  114. 
21 


242  DR.  Murray's  case. 

to  be  going  on  well  until  the  12tli,  after  which  the  tumor 
gradually  increased;  and  on  the  24th  the  integuments  were 
tense  and  shining,  and  there  was  considerable  pain."*  Mr. 
James  accordingly  felt  it  his  duty  to  give  his  patient  the  only 
remaining  chance,  by  putting  a  ligature  round  the  aorta.  The 
operation  was  accordingly  performed,  on  the  5th  of  July,  in 
the  manner  practised  by  Sir  A.  Cooper.  We  shall  find,  farther 
on,  that  the  aorta  may  in  general  be  tied  without  wounding 
the  peritoneum;  but  in  this  case  it  would  have  been  impracti- 
cable, as  the  serous  membrane  adhered  firmly  to  the  anterior 
surface  of  the  tumor.  The  patient  died  on  the  evening  of  the 
day  on  which  the  operation  was  performed;  and  on  opening 
the  body  a  remarkable  anomaly  was  observed;  the  external 
iliac  artery  divided,  above  Poupart's  ligament,  into  two 
branches;  one  of  which  gave  off  the  epigastric,  and  after- 
wards represented  the  profunda,  while  the  other  took  the 
course  of  the  femoral  artery. 

Dr.  Murray^ s  Case. — A  Portuguese  sailor  applied  at  the 
Civil  Hospital,  at  the  Cape  of  Good  Hope,  with  a  large  aneu- 
rismal  tumor  over  the  site  of  the  external  iliac  artery. 

^^The  tumor  now  presents  the  greatest  size  and  prominence 
immediately  above  Poupart's  ligament,  in  the  site  of  the  ex- 
ternal iliac  artery.  The  most  prominent  part  is  tense,  shin- 
ing, and  circumscribed,  about  the  size  of  an  orange,  and  its 
hard  irregular  base  extends  upwards  to  an  imaginary  line 
drawn  from  the  umbilicus  to  the  lower  ribs,  and  downwards 
to  a  couple  of  inches  below  Poupart's  ligament;  its  lateral 
boundaries  being  formed  by  the  ilium  and  linea  alba.  Pulsa- 
tion is  felt  in  the  prominent  part  of  the  tumor,  and  a  sort  of 
whizzing  sound  is  indistinctly  discovered  in  it  on  the  applica- 
tion of  the  ear  or  stethoscope;  but  there  appears  to  be  no 
circulation  in  the  femoral  artery.  He  does  not  complain  of 
much   pain   in   the   tumor   at   present,  but  says  it  is  often 

*  Med.  Ch.  Trans.,  vol.  xvi,  p.  1. 


243 

excruciatingly  severe  along  the  thigh-bone  and  in  the  knee. 
The  limb  is  much  swollen,  and  he  keeps  it  constantly  in  the 
bent  position,  and  cannot  bear  to  have  it  extended.  The 
skin  is  nearly  insensible  to  the  touch,  and  even  to  pinching, 
particularly  on  the  inner  part  of  the  thigh;  yet  he  describes 
having  a  feeling  as  if  worms  and  flies  were  creeping  over  it. 
Temperature  of  the  diseased  limb,  92  degrees,  and  of  the 
sound  one,  97.  Pulse  96,  and  intermittent;  and  the  action 
of  the  heart  has  a  corresponding  irregularity.  Two  or  three 
days  ago  he  had  an  attack  of  epistaxis.  Tongue  covered; 
respiration  natural;  intellect  clear.  Has  had  scarcely  any 
sleep  for  many  nights,  and  no  motion  in  his  bowels  for  eleven 
days." 

He  was  accordingly  taken  into  the  Hospital,  and  medicines 
calculated  to  palliate  his  symptoms  were  exhibited.  After  a 
few  days,  however,  matters  were  getting  manifestly  worse. 
His  features  were  shrunk  and  exsanguine,  limb  cold  and  in- 
sensible, and  the  tumor  enlarging  and  assuming  a  dark-bluish 
appearance  at  its  prominent  part.  He  complained  that  the 
friction  employed  to  preserve  the  temperature  of  the  limb 
was  only  increasing  his  pain,  and  the  greatest  agony  was  felt 
in  the  thigh  and  knee.  Under  these  circumstances,  it  was 
resolved  no  longer  to  defer  the  operation. 

"The  operation  had  to  be  performed  by  candle-light,  and, 
moreover,  as  he  lay  in  bed,  that'  he  might  not  be  put  to  the 
pain  of  being  moved  before  and  after  it. 

"  The  size  and  position  of  the  tumor  precluding  the  possi- 
bility of  reaching  the  aorta  by  cutting  from  the  right  side  of 
the  abdomen,  rendered  this  necessary  to  be  done  from  the  left, 
which  fortunately,  at  the  same  time,  had  the  advantage  of 
affording  the  readiest  and  easiest  access  to  the  vessel,  on 
account  of  its  anatomical  situation,  but  greatly  increased  the 
difficulty  of  reaching  the  right  common  iliac,  to  tie  it,  which 
it  was  hoped  might  be  found  possible. 

"  The  patient  lying  inclined  to  the  right  side,  the  first  in- 


244  DR.   MURRAY'S  CASE. 

cisiou  was  commenced  a  little  in  front  of  the  projecting  end 
of  the  tenth  rib,  and  carried  for  more  than  six  inches  down- 
wards, in  a  curvilinear  direction,  to  a  point  an  inch  in  front 
of  the  superior  anterior  spinous  process  of  the  ilium,  its  con- 
vexity being  towards  the  spine.  The  skin,  the  subcutaneous 
cellular  tissue,  and  the  aponeurosis  of  the  external  oblique 
muscle,  were  first  incised;  next  the  fibres  of  this  muscle;  and 
successively  afterwards  the  layers  of  the  internal  oblique  and 
transversalis  muscles  were  displayed  and  divided;  which  was 
found  rather  a  delicate  part  of  the  operation,  as  their  fibres 
contracted  spasmodically  when  touched  by  the  scalpel.  The 
fascia  transversalis  was  now  brought  beautifully  into  view, 
and  cautiously  divided  by  a  pair  of  scissors  upon  a  director, 
to  avoid  wounding  the  peritoneum.  This  membrane  being 
now  completely  laid  bare  to  nearly  the  whole  extent  of  the 
external  wounds,  was  next  detached  from  the  fascia  covering 
the  iliacus  internus  and  psoas  muscles,  chiefly  by  the  hand, 
introduced  flat  between  these  parts,  to  separate  the  loose 
cellular  substance  connecting  them,  which  was  easily  effected. 
"Whilst  detaching  the  peritoneum  in  the  fossa  of  the 
psoae,  I  found  my  fingers  get  into  a  soft  pulpy  mass,  and  a 
good  deal  of  dark  bloody  fluid  began  to  ooze  out  by  the  side 
of  my  hand,  which  made  me  withdraw  it  and  examine  the 
parts  by  throwing  a  ray  of  candle-light  into  the  bottom  of  the 
wound,  when,  from  the  dark  appearance  of  the  parts,  my  first 
impression  was  that  they  were  in  a  gangrenous  state;  but  I 
soon  discovered  that  it  was  caused  by  ecchymosis,  or  eff"usion 
of  bloody  serum  into  the  loose  cellular  texture.  I  then  reintro- 
duced my  hand,  and  gradually  prosecuted  the  detaching  of 
the  peritoneum  in  the  direction  of  the  spine,  till  I  came  to  a 
large  pulsating  vessel,  which  I  found  to  be  the  upper  part  of 
the  left  common  iliac,  and  in  another  minute  the  aorta  itself 
was  under  my  finger;  to  satisfy  myself  of  which,  I  requested 
one  of  the  gentlemen  assisting  me  to  place  his  ear  on  the 
tumor,  and  his  hand  on  the  left  femoral   artery,  when  he 


245 

heard  and  felt  the  pulsation  to  stop  and  recommence  in  each, 
as  I  compressed  the  vessel,  or  the  contrary.  I  now  endea- 
vored to  reach  the  right  common  iliac,  but  found  that  the 
walls  of  the  tumor  extended  nearly  close  up  to  the  bifurca- 
tion of  the  aorta;  and,  even  had  this  obstacle  not  existed,  I  do 
not  think  there  is  scope  for  the  hand  to  perform  the  neces- 
sary manipulations  to  place  a  ligature  upon  that  vessel  from 
the  left  side,  without  using  a  degree  oJP  force,  and  causing  a 
laceration  of  parts,  that  would  be  inconsistent  with  due  pro- 
fessional caution,  humanity,  and  judgment. 

"  A  tedious  and  rather  difficult  part  of  the  operation  suc- 
ceeded; viz.,  the  making  a  division  in  the  aortic  plexus  of 
nerves,  and  in  the  membranous  sheath  covering  the  aorta,  to 
get  betwixt  the  vessel  and  the  spine,  which  I  effected  partly 
by  the  steel  end  of  an  elevator  cranii,  but  chiefly  by  my  nails, 
with  my  mind  at  my  fingers'  ends;  and  I  was  not  a  little 
rejoiced  when  I  had  got  a  sufficient  separation,  to  be  able  to 
insert  the  point  of  the  aneurism-needle  beyond  and  behind 
it;  after  which  I  was  soon  able  to  get  it,  with  the  ligature, 
round  the  vessel,  without  including  any  portion  of  nerve  or 
other  extraneous  substance.  In  this  manoeuvre  it  was  with 
difficulty  that  the  longest-handled  aneurism-needle  could  be 
made  to  reach  the  necessary  depth.  The  ends  of  the  liga- 
tures being  brought  out,  the  aorta  was  gently  raised  upon  it, 
which  enabled  us,  by  holding  up  the  peritoneal  bag,  to  see 
this  great  vessel  pulsating  at  an  awful  rate. 

"  The  noose  of  the  ligature  was  then  gradually  tightened 
till  all  pulsation  and  circulation  was  found  to  have  deci- 
dedly ceased  in  the  left  groin;  and  we  anxiously  watched 
the  general  effect  upon  the  patient  whilst  this  and  the  second 
knot  were  being  tied. 

"  The  pulse  at  the  wrist,  during  the  time,  underwent  no 
sensible  alteration,  either  in  strength,  fulness,  or  frequency; 
nor  did  the  vasculur  organization  of  the  head  seem  to  be 
abnormally  congested  or  excited  by  the  sudden  check  to  this 

21* 


246  DR.  Murray's  case. 

great  stream  of  the  circulation.  The  tightening  of  the  knot 
did  not  seem  to  occasion  him  any  great  pain,  nor  to  cause  any 
unusual  sensation  or  shock  in  the  vascular,  nervous,  or  respi- 
ratory systems.  His  first  complaint  was,  that  his  left  leg  had 
hecome  as  henumhed  and  useless  as  his  right,  and  that  we  had 
done  him  bad  service  in  laming  his  good  leg,  which  he  did 
not  expect,  and  lamented  it  bitterly :  on  feeling  the  aorta,  it 
was  found  to  be  full,  and  pulsating  with  very  great  strength, 
above  the  ligature,  but  empty  and  motionless  below  it.  The 
ends  of  the  ligature  were  now  brought  out  exteriorly,  and 
the  lips  of  the  wound  drawn  together  by  three  sutures  and 
adhesive  straps,  over  which  a  compress  and  bandage  were 
applied. 

"The  operation  was  more  tedious  than  difficult;  and  being 
effected  chiefly  out  of  sight  by  the  hand,  it  had  not  the 
terrific  appearance  which  that  by  the  method  of  cutting  into 
the  cavity  of  the  abdomen  must  have,  and  it  was  accom- 
plished with  the  loss  of  less  than  two  ounces  of  blood.  At 
one  time,  during  its  performance,  he  required  to  get  some 
brandy  and  water  to  support  him;  but  when  it  was  over,  he 
seemed  quite  as  well  as  before  its  commencement;  and  the 
pulse  was  128,  steady  and  regular.'^ 

After  the  operation  he  felt  deadness  of  the  left  thigh  and 
leg,  and  complained  of  painful  distention  of  the  bladder, 
though  it  was  empty.  Afterwards  he  became  easier,  and 
smoked  a  cigar,  and  slept  a  little  at  intervals.  Soon,  however, 
he  began  to  complain  of  violent  pain  in  the  pubic  region  and 
loins.  Tongue  was  now  dry  and  dark,  strong  pulsation  of  the 
carotid,  and  feeble  pulse  at  the  wrist,  followed  by  jactitation : 
cold  clammy  sweats.  No  natural  warmth  ever  returned  to 
the  lower  limbs,  and  he  died  twenty-three  hours  after  the 
operation.  On  dissection,  it  was  found  that  the  artery  had 
been  secured  opposite  the  interval  between  the  fourth  and 
fifth  lumbar  vertebrae ;  no  extraneous  substance  was  included, 
and  "the  aortic  plexus  of  nerves  had  been  accurately  di- 


DR.  MONTEIRO'S  CASE.  247 

vided."  Specks  of  ulceration  were  observed  on  the  mucous 
membrane  of  the  bladder. 

The  vessels  of  the  lower  part  of  the  body  having  been 
injected,  a  few  drops  of  the  size  injection  were  found  in  a 
small  anastomosing  vessel,  discovered  passing  between  the 
inferior  mesenteric  artery  and  left  internal  iliac;  it  arose 
about  two  and  a  half  inches  below  the  origin  of  the  mesen- 
teric artery,  (from  the  hemorrhoidal  branch  of  it,  which 
seemed  larger  than  usual,)  and  joined  one  of  the  upper 
branches  of  the  internal  iliac,  being  in  length  about  two 
inches;  but  its  calibre  was  so  small,  having  only  admitted  two 
or  three  drops  of  the  colored  size,  that  it  probably  never 
carried  red  blood  during  life.  No  corresponding  vessel  was 
to  be  found  on  the  right  side,  nor  could  any  further  anasto- 
moses be  discovered  between  the  arteries  of  the  abdominal 
aorta  and  those  of  the  pelvis  or  lower  extremities.  The 
branches  of  the  thoracic  aorta  were  not  injected,  and  there- 
fore not  examined.* 

Dr.  Monteird's  case.  The  subject  of  this  operation  la- 
bored under  a  large  false  aneurism,  forming  a  tumor  on  the 
lower  and  right  side  of  the  abdomen  and  upper  part  of  the 
thigh.  The  incisions  were  made  pretty  similar  to  those  in 
Dr.  Murray's  case.  The  operation  was  performed  at  Rio  Ja- 
neiro in  1842.  The  aorta  was  secured  within  the  ligature  after 
a  good  deal  of  difficulty  in  the  operation:  the  patient  died 
at  the  expiration  of  the  tenth  day  after,  from  hemorrhage, 
which  took  place  from  a  small  opening  in  the  vessel  close  to 
the  ligature.  On  examination  after  death  it  was  found  that 
the  ligature  had  been  applied  about  four  lines  above  the 
bifurcation  of  the  aorta,  and  that  the  precise  nature  of  the 
original  disease  was  an  aneurism  of  the  femoral  artery  in 
which  the  coats  of  the  vessel  had  given  way. 

Mr.   South's  case.     No  authentic  report  of   Mr.   South's 

*  Lond.  Med.  Gaz.,  1834. 


248  MR.  south's  case. 

operation  of  ligature  of  the  abdominal  aorta  has  been  as  yet 
published  by  himself;  he  has,  however,  most  kindly  favored  me 
with  the  following  interesting  particulars  connected  with  his 
case : — "  The  man  was  thirty  years  of  age  and  a  hard  drinker, 
— had  had  a  strange  uneasy  sensation  two  months  before  his 
admission,  and  six  weeks  after  noticed  a  small  hard  pulsating 
swelling  in  his  right  groin,  which  grew  rapidly,  and  when 
admitted  was  as  big  as  a  goose  egg. — Soon  suffered  paroxysms 
of  violent  pain,  and  leg  became  numb.  Eleven  days  after, 
the  aorta  was  tied  without  difficulty  by  a  cut  from  the  tip 
of  the  tenth  rib  to  the  superior  iliac  spine.  In  course  of  a 
few  hours,  first  one,  and  subsequently  the  other  limb  became 
discolored;  was  in  constant  profuse  perspiration,  and  exceed- 
ingly restless.  Died  forty-two  hours  after.  Examination 
showed  false  aneurism  of  right  external  iliac  artery." 

The  foregoing  cases  suggest  the  following  considerations : — 
In  certain  wounds  the  ligature  of  the  aorta  may  be  attempted : 
— in  aneurism  it  can  only  be  had  recourse  to  in  order  to  pro- 
long life  for  a  few  days,  a^no  surgeon  would  venture  to  pro- 
pose so  serious  an  operation  for  an  early  aneurism;  and  in  an 
old  one  it  will  in  all  probability  fail,  or  may  hasten  the  death 
of  the  patient.  Under  these  circumstances,  would  it  not  be 
more  advisable  to  have  recourse  to  internal  or  medical  treat- 
ment than  to  propose  an  operation  of  so  serious  a  character, 
and  which  we  have  no  reason  for  hoping  may  be  attended 
with  success?  In  considering  the  dangers  and  difficulty  of 
the  operation,  it  may  be  well  to  observe  that  Dr.  Murray's 
case  shows  that  the  aorta  may  be  generally  tied,  without 
wounding  the  peritoneum;  and  Mr.  South's  case  that  it  may 
be  tied  "  without  difficulty.'^ 

The  branches  of  the  abdominal  aorta  are  the  following,  and 
from  above  downwards  they  arise  in  the  following  order : — 

Proper  Phrenic,  or  Renal. 

Sub-Phrenic.  Spermatic. 


CffiLIAC   AXIS.  249 

Coeliac  Axis.  Inferior  Mesenteric.    . 

Superior  Mesenteric.  Lumbar. 

Capsular.  Middle  Sacral. 

These  arteries  should,  however,  be  dissected  in  the  succeed- 
ing order : — 

The  CcELiAC  Axis  may  be  exposed  by  either  of  the  follow- 
ing methods :  the  liver  may  be  drawn  upwards  and  the  sto- 
mach downwards;  by  this  means  the  gastro-hepatic  or  lesser 
omentum  which  connects  them,  will  be  brought  into  view: 
the  anterior  layer  of  this  portion  of  the  peritoneum  being 
divided  with  caution  near  the  pyloric  end  of  the  stomach,  the 
hepatic  vessels  will  be  exposed,  and  the  hepatic  artery,  by 
this  dissection,  may  be  easily  traced  to  its  origin.  The  coeliac 
axis  may  be  also  exposed  by  turning  up  the  stomach  together 
with  the  liver,  and  by  tearing  through  the  transverse  meso- 
colon so  as  to  arrive  at  the  back  part  of  the  gastro-hepatic 
omentum.  This  artery  arises  opposite  the  body  of  the  twelfth 
dorsal  vertebra,  and  takes  a  direction  downwards,  forwards, 
and  more  frequently  to  the  left  than  to  the  right  side.  After 
a  course  of  about  half  an  inch,  it  terminates  by  dividing  into 
the  gastric,  hepatic,  and  splenic  arteries.  The  coeliac  axis  has 
the  superior  margin  of  the  pancreas  beneath  it,  and  this  gland 
is  frequently  notched  by  the  artery  in  this  situation :  on  its 
sides  are  the  crura  of  the  diaphragm,  and  the  semilunar  gan- 
glia, which  unite  both  above  and  below  the  artery,  so  as  to 
form  a  nervous  collar  around  its  origin,  from  which  streams 
forth  a  tube  of  nervous  filaments,  forming  the  solar  plexus, 
which  surrounds  the  artery.  In  front  of  this  artery  we  find 
the  lesser  omentum ;  the  Spigelian  lobe  of  the  liver  lies  above 
and  to  its  right  side. 

The  branches  given  off  by  the  coeliac  axis  are  the  fol- 
lowing : — 

Gastric,  or  Hepatic. 

Coronaria  Ventriculi.  Splenic. 


250  HEPATIC   ARTERY. 

The  Gastric  artery,  or  Coronaria  Yentriculi,  is 
smaller  than  the  hepatic  or  splenic ;  it  proceeds  at  first  up- 
wards, forwards,  and  to  the  left  side,  to  reach  the  cardiac 
orifice  of  the  stomach :  in  this  situation  it  often  sends  a  large 
branch  to  the  left  lobe  of  the  liver ;  but  its  constant  branches 
are — first,  an  oesophageal  branch  or  branches,  which  ascend, 
one  in  front  of,  the  other,  the  more  remarkable,  behind  the 
oesophagus :  they  supply  this  tube  and  anastomose  with  the 
oesophageal  branches  of  the  thoracic  aorta;  secondly,  some 
coronary  branches,  which  surround  the  cardiac  orifice;  and, 
thirdly,  a  long  descending  branch,  which  follows  the  lesser 
curvature  of  the  stomach,  lying  in  a  kind  of  triangular  canal 
situated  between  the  layers  of  the  lesser  omentum  and  the 
stomach :  the  artery  is  in  this  situation  accompanied  by  some 
lymphatic  vessels  and  glands,  and  by  several  branches  of  the 
left  pneumogastric  nerve:  it  sends  numerous  divisions  over 
both  surfaces  of  the  stomach,  and  thus  communicates  with 
the  arteries  running  along  its  convex  margin.  Having  arrived 
near  the  pylorus,  it  terminates  in  anastomosing  with  the  supe- 
rior pyloric,  which  is  a  branch  of  the  hepatic  artery. 

We  shall  find  that  not  the  gastric  artery  only,  but  the  three 
divisions  of  the  coeliac  axis  supply  the  stomach,  so  that  its 
margin  is  in  fact  circumscribed  by  vessels.  The  gastric 
branches  of  these  vessels  are  situated  between  the  layers  of 
the  peritoneum,  and  are  not  in  contact  with  the  margins  of 
the  stomach,^unless  in  its  distended  state:  this  observation 
does  not  apply  to  the  minute  divisions  which  ramify  on  both 
surfaces  of  this  viscus. 

The  Hepatic  Artery  is  smaller  than  the  splenic  in  the 
adult,  but  larger  in  the  foetus:  it  proceeds  at  first  almost 
transversely  along  the  superior  margin  of  the  pancreas,  and 
beneath  the  Spigelian  lobe  of  the  liver,  towards  the  upper  and 
posterior  surface  of  the  pyloric  extremity  of  the  stomach :  in 
this  situation  it  gives  off"  two  branches,  viz.,  the  pylorica  supe- 
rior and  gastro-duodenalis,  and  then  proceeds  upwards,  for- 


ARTERIES   OP    STOMACH   AND   LIVER. 


251 


Fig.  ob.— Represents  the  Arteries  of  the  Stomach  and  Liver. 


A,  Abdominal  Aorta.  B,  Coeliac  Axis.  D,  Hepatic  Artery.  E,  Tlie  Splenic  Artery,  a,  a,  Proper 
Phrenic  or  Sub-phrenic  Arteries,  b.  Anterior  (Esophageal  branch  from  Coronary  Artery,  c,  c, 
Gastric  or  Coronary  Artery,  d,  Hepatic  Artery,  e,  Superior  Pyloric  Artery  anastomosing  with 
the  descending  branch  of  Gastric  Artery,  f.  The  Vena  Portae.  g,  Left  Hepatic  Artery,  i, 
Right  Hepatic  Artery,    k.  Cystic  Artery,    m,  Ductus  Choledochus  Communis,    n,  Hepatic  Duct. 

1,  Union  of  Cystic  and  Hepatic  Ducts,  to  form  the  Ductus  Communis,  o,  The  Gastro-duodenalis 
Artery,  p,  Gastro-epiploica  Dextra  Artery.  3,  q,  Anastomosis  between  the  Right  and  Left  Epiploic 
Arteries,    r,  r,  r,  Omental  branches  from  Epiploic  Artery.    1,  Under-surface  of  right  Lobe  of  Liver. 

2,  Gall-bladder.  3,  Under-surface  of  left  Lobe  of  Liver.  4,  Lobulus  Spigelii.  5,  5,  Pillars  of  the 
Diaphragm.  6,  {Esophagus.  7,  8,  9,  Stomach.  10,  Pylorus.  11,  Duodenum.  12,  12,  12,  12,  The 
Great  Omentum.    13,  13,  13,  The  Small  Intestines.    14,  14,  Peritoneum. 


252  CIRCULATION    IN    THE    LIVER. 

wards,  and  to  the  right  side,  surrounded  by  a  considerable 
quantity  of  areolar  tissue  and  branches  of  the  solar  plexus  of 
nerves,  all  of  which  are  situated  between  the  two  layers  of 
the  lesser  omentum :  in  this  part  of  its  course  it  has  the  vena 
portae  behind  it,  and  the  ductus  choledochus  to  its  right  side. 
Having  arrived  in  this  manner  within  about  an  inch  of  the 
liver,  it  terminates  by  dividing  into  the  right  and  left  hepatic 
arteries,  having,  as  already  stated,  previously  given  oflf  the 
superior  pyloric  and  gastro-duodenalis. 

The  Superior  Pyloric  artery  is  small,  and  descends  from 
right  to  left  along  the  lesser  curvature  of  the  stomach :  it 
supplies  this  organ,  and  anastomoses  directly  with  the  descend- 
ing branch  of  the  gastric  artery,  and  by  small  branches  which 
run  across  the  stomach  both  anteriorly  and  posteriorly,  with 
the  arteries  running  along  the  great  curvature  of  the  stomach. 
The  superior  pyloric  sometimes  arises  from  the  right  hepatic. 

The  Gastro-duodenalis  artery,  about  two  inches  in  length, 
descends  behind  the  first  portion  of  the  duodenum,  which  it 
separates  from  the  head  of  the  pancreas,  and  divides  into  the 
gastro-epiploica  dextra,  and  the  pancreatico-duodenalis :  the 
gastro-epiploica  dextra,  considerably  larger  than  the  latter, 
proceeds  from  right  to  left  along  the  greater  curvature  of  the 
stomach,  both  surfaces  of  which  it  supplies,  and  terminates  in 
anastomosing  with  the  gastro-epiploica  sinistra,  which  is  a 
branch  of  the  splenic:  its  stomachic  branches  anastomose 
with  the  superior  pyloric  and  gastric  artery,  and  with  the 
vasa  brevia,  while  other  long  straight  branches  descend  from 
its  convexity,  between  the  layers  of  the  great  omentum,  to 
supply  the  transverse  colon.  The  pancreatico-duodenalis, 
very  small,  descends  between  the  head  of  the  pancreas  and 
second  portion  of  the  duodenum :  it  supplies  both  of  these 
parts,  and  sends  a  delicate  branch  between  the  inferior  margin 
of  the  pancreas,  and  the  third  portion  of  the  duodenum,  to 
anastomose  with  the  superior  mesenteric  artery. 

The  right  terminating  branch  of  the  hepatic  artery  ascends 


CIRCULATION    OF   THE   BLOOD    IN   THE    LIVER.         253 

between  the  hepatic  and  cystic  ducts  anteriorly,  and  the  vena 
portaB  and  its  right  branch  posteriorly,  and  sinks  into  the 
right  extremity  of  the  transverse  fissure,  to  supply  the  liver : 
immediately  after  having  passed  behind  the  hepatic  duct  it 
gives  off  the  cystic  artery,  which  ascends  between  the  hepatic 
and  cystic  ducts,  and  divides  into  two  branches,  one  of  which 
is  distributed  on  the  superior  and  the  other  on  the  inferior 
surface  of  the  gall-bladder. 

The  left  terminating  branch  of  the  hepatic  artery,  smaller 
than  the  right,  ascends  in  front  of  the  left  branch  of  the  vena 
portaB,  ultimately  gets  behind  it,  and  sinks  into  the  left  ex- 
tremity of  the  transverse  fissure  to  supply  the  liver. 

CIRCULATION  OP  THE  BLOOD  IN  THE  LIVER. 

The  Vena  Portse,  is  formed  by  the  junction  of  the  splenic 
vein,  after  it  has  received  the  inferior  mesenteric,  with  the 
superior  mesenteric  vein.  The  trunk  of  this  large  vein  com- 
mences on  the  front  of  the  aorta,  behind  the  superior  margin 
of  the  pancreas,  and  opposite  to  the  first  lumbar  vertebra :  it 
then  takes  a  direction  upwards,  and  to  the  right  side,  to  reach 
the  transverse  fissure  of  the  liver,  in  which  it  divides  into  a 
right  and  left  branch.  In  this  course  it  is  at  first  behind  and 
between  the  hepatic  artery  and  ductus  choledochus,  and  higher 
up  it  is  directly  behind  them.  In  the  adult,  the  right  branch, 
shorter  and  larger  than  the  left,  and  more  in  the  direction  of 
the  trunk  itself,  soon  sinks  into  the  right  extremity  of  the 
transverse  fissure,  to  supply  the  right  lobe ;  the  left  proceeds 
in  the  opposite  direction,  takes  a  longer  course,  forming  nearly 
a  right  angle  with  the  trunk,  and  sinks  into  the  left  lobe. 

We  shall  now  endeavor  to  explain  the  distribution  of  these 
vessels  in  the  foetus,  and  the  manner  in  which  the  subsequent 
changes  in  their  arrangement  are  efi'ected. 

The  Umbilical  Vein  in  the  Foetus  runs  obliquely  upwards, 
backwards,  and  to  the  right  side,  in  the  posterior  or  free  margin 
of  the  falciform  ligament  of  the  liver :  having  arrived  in  the 

22 


254  CIRCULATION   OF   THE   FCETAL   LIVER. 

umbilical  or  horizontal  fissure  of  this  gland,  it  sends  several 
branches  to  its  left  lobe,  and  one  or  two  small  ones  to  the  lo- 
bulus  quadratus;  then  continuing  its  course  backwards,  it  re- 
ceives the  left  branch  of  the  vena  portae;  after  having  com- 
municated with  this  branch,  it  passes  between  the  Spigelian 
and  left  lobes  of  the  liver,  and  in  this  part  of  its  course  re- 
ceives the  name  of  the  ductus  venosus,  which  terminates 
finally  in  the  inferior  cava,  or  left  hepatic  vein. 

The  Vena  Portse  in  the  Foetus  divides  into  two  branches ; 
one  of  which  sinks  into  the  right  lobe,  the  other  runs  towards 
the  left  lobe  of  the  liver  and  terminates  in  communicating  with 
the  umbilical  vein. 

On  examining  the  distribution  of  these  two  large  veins  in 
the  fa3tal  liver,  we  will  perceive  that  in  reality  the  right  lobe 
receives  blood  from  the  vena  portae  only,  but  the  left  from 
both  the  portal  and  umbilical  veins.  This  explains  why  the 
left  lobe  is  so  well  developed  at  this  period  of  life.  After 
birth,  however,  the  ductus  venosus  becomes  entirely  oblite- 
rated, but  of  the  umbilical  vein  its  left  branches  and  a  part 
of  its  trunk  remain  pervious,  viz.,  that  part  of  it  in  the  im- 
mediate neighborhood  of  the  transverse  fissure ;  for  otherwise 
there  would  be  no  way  for  the  blood  of  the  porta  to  arrive  at 
the  left  lobe  of  the  liver.  All  the  rest  of  the  umbilical  vein 
is  obliterated. 

The  use  generally  ascribed  to  the  vena  portSB  is  to  convey 
to  the  liver  the  materials  for  the  secretion  of  the  bile.  Some, 
however,  insist  that  the  bile  is  secreted  from  arterial  blood  j 
and  others,  as  Mr.  Phillips,  that  it  may  be  indifferently 
secreted  from  either.  In  favor  of  the  secretion  from  the 
portal  blood,  it  has  been  said  that  the  bile  is  of  an  oily  cha- 
racter, and  that  the  venous  blood,  being  highly  charged  with 
carbon  and  hydrogen,  is  the  best  suited  for  its  production. 
To  this  it  has  been  replied,  that  fat,  though  compounded  of 
carbon  and  hydrogen,  is  nevertheless  separated  by  exhalation 
from  the  arterial  blood.     Again,  the  size  of  the  vena  portae 


MR.  kiernan's  investigations.  255 

is  said  by  those  who  suppose  the  bile  derived  from  it,  to  be 
suited  to  the  size  of  the  liver ;  while  the  other  party  reply, 
that  the  vessel  should  be  compared  with  the  duct  and  not 
with  the  gland,  they  maintain  that  there  is  a  proper  propor- 
tion between  the  size  of  the  hepatic  artery  and  hepatic  duct. 
There  are  at  least  four*  cases  on  record,  in  which  the  vena 
portae  did  not  go  at  all  to  the  liver,  but  terminated  in  the 
inferior  cava.  It  would  appear,  however,  that  in  one  of  these 
cases  the  portal  system  of  the  liver  was  not  absent,  but  the 
peculiarity  was,  that  it  commenced  in  a  cul  de  sac.  The 
same  would  probably  be  found  in  the  other  cases  if  they  had 
been  accurately  examined.  M.  Simon  found,  that  if  the 
hepatic  artery  be  tied  in  pigeons,  the  secretion  of  the  bile 
continues ;  if  the  portal  vein  and  ducts  be  tied,  it  ceases ;  and 
if  the  ducts  alone  be  tied,  the  liver  is  gorged  with  bile.  Mr. 
Phillips  infers  from  his  experiments,  that  the  blood  may  be 
secreted  from  the  blood  of  either  artery  or  vein,  as,  whichever 
vessel  was  tied,  the  secretion  continued. 

We  shall  now  present  the  student  with  an  abstract  of  Mr. 
Kiernan's  valuable  observations  concerning  the  circulation 
and  structure  of  the  liver.  Previous  to  his  researches,  it  was 
supposed  that  the  liver  consisted  of  two  different  kinds  of 
substance,  termed  the  red  tissue  and  yellow  tissue.  Mr.  Kier- 
nan,  however,  by  a  series  of  well-conducted  experiments,  has 
shown  that  the  red  color  depends  on  congestion  of  the  blood- 
vessels, and  the  yellow  color  on  the  absence  of  it.  In  order 
to  make  this  more  clear,  let  us  attend  to  his  exposition  of  the 
structure  and  arrangement  of  the  vessels  in  the  liver.  Ac- 
cording to  Mr.  Kiernan,  each  lohule  of  the  liver  has  a  conical 
form,  and  when  divided  longitudinally  presents  a  foliated 
appearance ;  and  through  its  axis  passes  a  small  vein,  termed 

*  Lieutaud,  Hist.  Anat.  Med.,  torn.  i.  p.  190. 
Huber,  Observ.  Anat.,  p.  34. 
Abernethy,  Phil.  Trans.,  1793. 
Lawrence,  Med.  Chirurg.  Trans.,  vol.  v.  p.  174. 


256  MR.  kiernan's  investigations. 

the  intra-lohular  vein.  This  vein  terminates  at  a  right  angle 
in  a  larger  vein,  which  is  applied  to  the  base  of  the  lobule ; 
this  is  accordingly  called  a  suh-hhular  vein.  The  sub-lobular 
veins  terminate  in  the  vense  cavse  hepaticse^  and  these  again  in 
the  vena  cava  inferior.  Now,  all  that  portion  of  the  exterior 
of  a  lobule,  which  does  not  constitute  its  base,  is  termed  its 
capsular  surface,  because  it  is  in  contact  with,  and  separated 
from,  the  surrounding  lobules  by  a  process  of  the  capsule  of 
Glisson,  which  serves  as  a  capsule  for  the  lobule.  Mr.  Kier- 
nan  considers  that  the  capsule  of  Glisson  "is  to  the  liver 
what  the  pia  mater  is  to  the  brain;  it  is  a  cellulo-vascular 
membrane,  in  which  the  vessels  divide,  and  subdivide  to  an 
extreme  degree  of  minuteness;  it  lines  the  portal  canals, 
forming  sheaths  for  the  larger  vessels  contained  in  them,  and 
a  web  in  which  the  smaller  vessels  ramify ;  it  enters  the  inter- 
lobular fissures,  and  with  the  -vessels  forms  the  capsules  of 
the  lobules;  and  it  finally  enters  the  lobules,  and  with  the 
blood-vessels,  expands  itself  over  the  secreting  biliary  ducts. 
Hence  arises  a  natural  division  of  the  capsule  into  three  por- 
tions, a  vaginal,  an  interlobular,  and  a  lobular  portion  ;  and 
as  the  vessels  ramify  in  the  capsule,  their  branches  admit  of 
a  similar  division.''  Thus,  according  to  Mr.  Kiernan,  the 
capsule  of  Glisson  enters  the  transverse  fissure  of  the  liver, 
and  forms  an  internal  lining  for  those  canals  called  the  portal 
canals,  which  convey  the  larger  divisions  of  the  vena  porta3 
into  the  interior  of  the  organ;  this,  which  is  called  the  vaginal 
portion  of  the  capsule  of  Glisson,  invests  the  primary  divisions 
of  the  vena  portae,  hepatic  artery,  and  the  larger  portions  of 
the  hepatic  ducts :  the  term  vaginal  branches  has,  therefore, 
been  applied  to  these  divisions  of  the  vessels  surrounded  by 
the  vaginal  portion  of  the  capsule.  The  minute  divisions  of 
these  three  sets  of  vessels,  together  with  the  lobular  portion 
of  the  capsule  of  Glisson,  constitute  the  principal  part  of  the 
lobules,  so  that,  according  to  Mr.  Kiernan,  each  lobule  is 
composed,  "on  the  outer  surface  of  a  capsule  formed  by  a 


MR.  kiernan's  investigations.  257 

process  of  Glisson's  capsule,  of  a  plexus  of  biliary  ducts,  of  a 
venous  plexus  formed  by  branches  of  the  portal  vein,  of  a 
branch  of  an  hepatic  vein,  and  of  minute  arteries :  nerves 
and  absorbents,  it  is  to  be  presumed,  also  enter  into  their 
formation,  but  cannot  be  traced  to  them.'^  By  taking  the 
duct,  artery,  and  vena  portae  separately,  we  shall  find  how 
they  are  disposed  of  in  the  liver.  First ;  the  ditcts  penetrate 
the  capsular  surfaces  of  the  lobules,  and  form  in  the  interior 
of  each,  an  extensive  lobular  hiliar?/  plexus ;  from  this  plexus 
the  bile  passes  into  the  interlobular  branches,  and  then  into 
the  vaginal  biliary  plexus  which  goes  to  form  the  hepatic 
ducts.  Secondly;  when  the  branches  of  the  hepatic  artery 
pass  into  the  portal  canals,  they  give  off  vaginal  branches ; 
these  form  the  vaginal  plexus  of  arteries  which  gives  off  the 
interlobular  branches;  these  pass  through  the  interlobular 
fissures  and  give  off  the  lobular  branches  which  also  pene- 
trate the  capsular  surface  of  the  lobules:  they  supply  the 
parenchyma  of  the  lobules,  and  the  coats  of  all  the  vessels ; 
and  the  surplus  quantity  of  blood  not  required  for  the  nutri- 
tion of  these  parts,  is  conveyed  into  the  minute  branches  of 
the  vena  portaB.  Mr.  Kiernan  remarks  concerning  the  func- 
tion of  the  hepatic  arteries,  "I  conclude  that  the  secreting 
portion  of  the  liver,  like  the  excreting  portion  of  the  kidney, 
is  supplied  with  arterial  blood  for  nutrition  only.  As  all  the 
branches  of  the  artery  of  which  we  can  ascertain  the  termi- 
nation, end  in  branches  of  the  portal  vein,  it  is  probable  that 
the  lobular  arteries  terminate  in  the  lobular  venous  plexus 
formed  by  that  vein,  and  not  in  the  intra-lobular  branches 
of  the  hepatic  veins,  which  cannot  be  injected  from  the 
artery,  the  blood  of  these  arteries,  after  having  nourished  the 
lobules,  becoming  venous,  and  thus  contributing  to  the  secre- 
tion of  bile."  Thirdly  ;  after  the  vena  portse  has  reached  the 
transverse  fissure  of  the  liver,  it  divides  into  branches  which 
enter  into  the  portal  canals  :  here  they  give  off  the  vaginal 
branches  which  constitute  the  vaginal  plexus;  these  then 

22* 


258  MR.  kiernan's  investigations. 

give  oiF  the  interlobular  branches,  which  in  their  turn  give 
off  the  lobular  branches.  Finally ;  these  last,  after  piercing 
the  capsular  surface  of  the  lobules,  form,  in  their  interior,  a 
portal  plexus  or  the  lohular  venous  plexus  of  the  porta,  which, 
having  received,  as  above  mentioned,  part  of  the  blood  con- 
veyed by  the  arteries,  furnishes  the  material  for  the  secretion 
of  the  bile.  Hence  it  appears  that  the  bile  is  not  secreted 
from  arterial  blood,  but  from  venous  derived  from  two 
different  sources,  one  from  the  returned  blood  of  the  hepatic 
arteries  which  flows  into  the  portal  veins,  the  other  from  the 
venous  blood  of  the  porta  itself.  Thus,  the  branches  of  the 
vena  portae  act  as  veins  to  the  hepatic  artery,  and  as  arteries 
to  the  hepatic  veins,  which  receive  the  surplus  quantity 
of  blood  not  employed  in  secretion.  Now  the  appearances  of 
the  yellow  and  red  tissues  can  be  readily  explained.  The  red 
tissue  is  owing  to  venous  congestion  :  when  this  occurs  in  the 
hepatic  system  of  veins,  the  centre  of  each  lobule  will  be 
dark  from  engorgement  of  the  intra-lobular  veins ;  and,  vice 
versa,  when  the  congestion  occurs  in  the  portal  system,  the 
centre  of  the  lobule  will  be  light  (constituting  the  appear- 
ance of  yellow  tissue),  but  the  circumference  red,  by  engorge- 
ment of  the  portal  veins  investing  it ;  so  that  in  one  case  we 
shall  have  dark  spots  on  a  pale  ground ;  and  in  the  other, 
pale  spots  on  a  dark  ground.  Mr.  Kiernan  could  produce 
these  appearances  at  pleasure,  in  experiments  on  animals, 
both  in  the  liver,  and  also  in  kidneys  of  those  animals  that 
have  a  portal  renal  circulation. 

According  to  Todd  and  Bowman,  in  the  human  subject  the 
lobules  are  not  isolated  by  a  distinct  capsule,  but  are  only 
imperfectly  marked  out  by  the  several  points  of  their  exterior, 
to  which  the  ultimate  twigs  of  the  portal  vein  and  duct 
arrive. 

The  Splenic  Artery  proceeds  from  its  origin  to  the  left 
side  in  a  very  tortuous  manner  along  a  groove  in  the  back 


SPLENIC   ARTERY. 


259 


part  of  the  upper  margin  of  the  pancreas :  posterior  to  it  are 
the  left  crus  of  the  diaphragm,  left  semilunar  ganglion,  and 
supra-renal  capsule  of  the  same  side ;  the  stomach  covers  it 

Fig.  3Q.— Distribution  of  the  Coeliac  Artery. 


1,  Liver  turned  upward,  and  showing  its  lower  surface.  2,  Transverse  Fissure.  3,  Gall-bladder. 
4,  Stomach.  5,  (Esophagus.  6,  7,  8,  Duodenum.  9,  Pancreas.  10,  Spleen.  11,  Aorta.  12,  Coeliac 
Arterj'.  13,  Coronary  Artery.  14,  Hepatic  Artery.  15.  Pyloric  Artery.  16,  Gastro-duodenal 
Artery.  17,  Right  Gastro-epiploic  Artery.  18,  Pancreaticoduodenal  Artery.  19,  Hepatic 
Artery  dividing  into  the  right  and  left  branches  for  the  Liver.  'ZO,  Spteuic  Artery  ;  its  course  indi- 
cated behind  the  stomach  by  dotted  lines  '21,  Left  Gastro-epiploio  Artery.  22,  Pancreatic  branch. 
23,  Gastric  branches.  24,  Superior  Mesenteric  Artery,  emerging  from  between  the  Pancreas  and 
Duodenum. 

in  front,  and  the  splenic  vein  lies  inferior  to  it,  and  in  the 
same  groove  in  the  pancreas.  Whilst  the  artery  is  remark- 
able for  its  tortuosity,  the  vein  presents  a  comparatively 
straight  course  from  the  hilus  lienis  to  its  termination  in  the 
porta.  On  approaching  the  spleen,  the  artery  divides  into 
five  or  six  terminating  branches,  which  enter  the  fissure,  or 
hilus  Uenis,  on  its  concave  surface.  The  branches  given  off 
by  the  splenic  artery  in  this  course  are,  first,  small  branches, 
pancreaticse,  parvse,  variable  in  number,  to  the  pancreas : 
secondly,  a  large  branch  to  the  pancreas,  pancreatica  magnay 


STRUCTURE   OF   SPLEEN. 

wliich  sometimes  aocompoDies  the  dnct  of  this  gland,  bat  is 
often  deficient :  thirdly,  the  vasa  brema,  some  of  which  come 
£nom  the  tronk  of  the  splenic,  and  others  from  the  branches 
which  enter  the  spleen ;  they  are  five  or  six  in  number,  and 
are  reflected  to  the  bulging  extremity  of  the  stomach,  where 
they  communicate  freely  with  the  other  arteries  supplying 
this  organ  :  lastly,  the  gastro-epiploica  sinistra  ^  which  some- 
times arises  fitmi  one  of  the  terminating  branches  of  the 
splenic,  and  proceeds  from  left  to  right  along  the  great  curva- 
ture of  the  stomach,  to  anastomose  with  the  gastro-epiploica 
dextra,  and  to  give  off  similar  ascending  and  descending 
blanches. 

When  the  arteries  penetrate  the  spleen,  they  soon  break 
abruptly  into  numerous  fine  branches,  compared  to  the  hairs 
of  a  camel-hair  pencil :  these  branches  do  not  communicate 
with  each  other,  but  terminate  in  veins  that  form  numerous 
plexuses.  There  are  no  cells  in  the  spleen,  as  formerly  repre- 
sented. The  following  passage,  describing  the  structure  of 
the  spleen,  is  extracted  from  Baly's  translation  of  31uller  : — 

**The  spleen  is  invested  by  a  strong  fibrous  membrane, 
which  sends  numerous  band-like  processes  into  its  interior,  so 
as  to  support  the  soft,  pulpy,  red  tissue  of  the  organ.  In  the 
red  substance  there  are  contained,  in  many  animals,  whitLsh, 
round  corpuscles,  visible  by  the  naked  eye,  which  were  first 
discovered  by  Blalpighi,  and  of  which  the  existence  in  the 
human  spleen  has  been  at  one  time  admitted,  at  another  denied. 

"  The  red  pxJpy  substance  consists  of  *a  mass  of  red-brown 
granules,  as  large  as  the  red  particles  of  the  blood,  but  differ- 
ing from  them  in  form,  being  irregularly  globular,  not  flat- 
tened. These  granules  are  easily  separable  from  each  other. 
In  the  mass  which  they  form,  the  minute  arteries  ramify  in 
tufts,  and  terminate  in  the  plexus  of  venous  canals,  into  which 
all  the  blood  of  the  spleen  is  poured  before  it  is  carried  out 
of  the  organ  by  the  splenic  vein.  The  anastomosing  venous 
radicles,  which  are  of  considerable  size,   appear   to   have 


SUPERIOR    MESENTERIC   ARTERY.  261 

scarcely  any  distinct  coats.  If  a  portion  of  the  pulpy  sub- 
stance of  the  spleen  is  examined  more  closely,  it  is  seen  to  be 
everywhere  perforated  with  small  foramina,  which  are  spaces 
bounded  by  the  reticulated  substance  of  the  organ.  These 
spaces  are  venous  canals :  on  inflating  them  the  organ  acquires 
a  cellular  appearance  j  and  if  they  are  injected  with  wax,  the 
substance  of  the  spleen  will  present  a  great  resemblance  to 
the  corpora  cavernosa  penis.  There  are  no  true  cells  in  the 
spleen.  The  white  corpuscles  are  imbedded  in  the  pulpy 
substance,  and  not  contained  in  cells,  as  Malpighi  supposed. 
A  fibrous  trabecular  tissue  intersects  in  all  directions  the  very 
sofl,  pulpy  red  substance,  and  affords  support  to  the  texture 
of  the  organ.*' 

Cruveilhier  observes,  that  if  we  inject  the  arteries  of  the 
spleen,  it  enlarges  slowly;  but  if  we  inject  the  veins,  it  en- 
larges at  once,  showing  that  the  connection  between  the 
arteries  and  the  venous  plexus  is  not  so  free  as  between  the 
latter  and  the  veins. 

In  speaking  of  the  veins  of  the  spleen,  Mr.  Gray  mentions 
three  modes  in  which  these  vessels  commence — firet,  as  con- 
tinuations of  the  capillaries  of  the  arteries;  this  is  the  most 
common  method  :  secondly,  in  intercellular  spaces  in  the  sub- 
stance of  the  pulpy  material  of  the  spleen,  through  which  the 
veins  communicate  with  each  other  :  thirdly,  by  forming  an 
imperfect  capsule  to  each  Malpighian  corpuscle.  This  last 
mode  of  the  commencement  of  the  veins  of  the  spleen  has 
not  been  described  by  other  writers  :  Mr.  Gray  eoosiders  that 
the  secretion  of  the  ^lalpighian  corpuscles  is  carried  into  the 
circulation  through  these  small  veins  which  form  this  capsule. 

The  Superior  3Iesenteric  Artery,  nearly  as  large  as 
the  coeliac  axis,  and  sometimes  even  larger,  arises  about  a 
quarter  or  half  an  inch  lower  down  than  that  vessel,  from 
the  aorta ;  it  first  descends  a  Httle  to  the  left,  behind  the 
splenic  vein  and  pancreas,  and  on  the  front  of  the  abdominal 


262  BRANCHES   OP   SUPERIOR   MESENTERIC. 

aorta ;  having  reached  the  lower  margin  of  the  pancreas,  it 
becomes  separated  from  the  aorta  by  the  third  portion  of  the 
duodenum,  and  the  left  renal  vein.  In  the  next  part  of  its 
course  it  descends  behind  the  transverse  mesocolon,  and  then 
between  the  laminae  of  the  mesentery,  to  arrive  at  the  ileum 
near  its  termination ;  it  then  ascends  along  this  intestine  to- 
wards the  caecum  :  in  this  course  it  has  its  vein  to  its  right 
side,  and  it  describes  a  curvature,  the  convexity  of  which 
looks  downwards  and  to  the  left  side.  It  first  gives  small 
branches  to  the  pancreas  and  diiodenuniy  which  anastomose 
with  the  pancreatico-duodenalis  artery ;  lower  down  it  gives 
off  two  sets  of  branches,  viz.,  one  from  its  convexity,  or  left 
side  'j  the  other  from  its  concavity,  or  right  side. 

The  Branches  from  the  Convexity  are  fifteen  to  twenty  in 
number :  they  are  contained  between  the  layers  of  the  mesen- 
tery, and  destined  for  the  ileum,  jejunum,  and  third  por- 
tion of  the  duodenum.  Each  of  them,  after  a  short  course, 
divides  into  two  branches,  which  anastomose  with  the  branches 
of  the  adjacent  arteries,  so  as  to  form  a  series  of  arches.  From 
the  convexities  of  these,  smaller  arteries  arise,  which  likewise 
bifurcate,  forming  a  second  and  lesser  series  of  arches  with 
those  adjacent;  and  in  the  same  manner  a  third  and  fourth, 
and,  in  some  cases,  a  fifth  series  is  formed,  gradually  approach- 
ing the  intestine,  and  diminishing  in  size  :  the  entire  arrange- 
ment presents  an  areolar  appearance  in  the  mesentery ;  and 
when  the  ultimate  branches  (which  advance  in  straight  lines) 
reach  the  intestine  for  which  they  are  destined,  they  encircle 
it,  and  form  a  delicate  vascular  stratum  in  its  sub-mcuous 
areolar  tissue. 

The  Branches  from  the  Concavity  are  three  in  number, 
viz. : 

Colica  Media,  Colica  Dextra,  and  Ileo-Colic. 

These  arteries  are  considerably  longer  than  the  preceding: 
they  are  contained  between  the  layers  of  the  mesocolon,  and 


BRANCHES   OF   SUPERIOR    MESENTERIC. 


263 


are  destined  to  supply  the  arch  of  the  colon,  the  right  or 
ascending  colon,  and  the  caecum,  with  part  of  the  ileum. 

The  CoUca  Media  goes  horizontally  forward  between  the 
laminae  of  the  transverse  mesocolon,  and  soon  divides  into  a 

Fig.  37. — Distribution  of  the  Superior  Mesenteric  Artery. 


1,  Superior  Mesenteric  Artery.  2.  Jejunal  and  Ileal  Arteries.  3,  Ileocolic  Artery.  4,  Right  Colic. 
5,  Middle  Colic  Artery.  6,  Duodenal  Artery,  a.  Small  Intestine  turned  to  the  left,  b,  Large  Intes- 
tine,   c,  Pancreas. 

right  and  a  left  branch;  the  former  of  which  anastomoses 
with  the  superior  branch  of  the  colica  dextra,  and  the  latter 
with  the  superior  branch  of  the  colica  sinistra,  which  is  a 
branch  of  the  inferior  mesenteric:  this  artery  supplies  the 
arch  or  middle  portion  of  the  colon. 

The  Colica  Dextra  passes   towards  the  right  colon,  near 
which  it  divides  into — a  superior  branch,  which  anastomoses 


264  INFERIOR   MESENTERIC   ARTERY. 

with  the  right  branch  of  the  colica  media;  and  an  inferior 
branch,  which  descends  to  anastomose  with  the  superior 
branch  of  the  ileo-colic  artery:  it  supplies  the  ascending 
colon. 

The  lleo-  Colic  branch  appears  to  be  the  termination  of  the 
superior  mesenteric ;  it  runs  downwards,  and  to  the  right  side, 
towards  the  caecum.  Before  it  reaches  the  intestine,  however, 
it  divides  into  three  branches, — the  sjqjcrwr  of  which  ascends 
to  anastomose  with  the  colica  dextra;  the  inferior  descends 
to  anastomose  with  the  terminating  branches  from  the  con- 
vexity of  the  superior  mesenteric  artery;  while  the  middle 
branch  passes  behind  the  caecum,  and  terminates  in  supplying 
the  ileum,  caecum,  and  vermiform  appendix. 

In  the  foetus,  the  superior  mesenteric  artery  gives  oif  an 
omphalo-meaenteric  branch,  which  proceeds  along  the  umbilical 
cord  to  be  lost  on  the  vesicula  umbilicalis.  It  is  usually  obli- 
terated at  the  end  of  the  second  month,  but  Cruveilhier  saw 
it  in  an  acephalous  foetus  at  the  ninth  month. 

The  Inferior  Mesenteric  Artery,  smaller  than  the 
preceding,  arises  from  the  anterior  and  left  part  of  the  aorta, 
about  an  inch  and  a  half  above  its  bifurcation.  It  first  de- 
scends on  the  aorta,  between  the  layers  of  the  mesocolon,  and 
then  turns  over  the  left  common  iliac  artery  to  terminate 
behind  the  rectum.  This  terminating  branch  is  called  the 
superior  haemorrhoidal.  In  the  above  course,  the  inferior 
mesenteric  artery  forms  an  arch,  the  convexity  of  which  looks 
to  the  left  side.     Its  branches  are  three  in  number : — 

Colica  Sinistra.  Arteria  Sigmoidea;  and 

Superior  Haemorrhoidal. 

The  Colica  Sinistra  ascends  between  the  layers  of  the  left 
mesocolon,  and  divides  into  a  superior  and  inferior  branch; 
the  former  anastomoses  with  the  colica  media,  and  the  latter 
with  the  sigmoid  artery. 


BRANCHES    OF   INFERIOR    MESENTERIC. 


265 


The  Sigmoid  artery  crosses  the  front  of  the  psoas  muscle, 
and  divides  into  a  superior  branch,  which  communicates  with 
the  colica  sinistra,  and  an  inferior  branch,  which  terminates 
in  supplying  the  sigmoid  flexure  of  the  colon,  and  in  anasto- 
mosing with  the  superior  hajmorrhoidal.  This  artery  also 
supplies  the  psoas  and  iliacus  muscles  and  the  ureter. 

Fig.  5S.— Distribution  of  the  Inferior  Mesenteric  Artery. 


1,  Aorta.  2,  Inferior  Mesenteric  Artery.  3 .  Left  Colic  Artery.  4,  Sigmoid  Artery.  S.Superior 
Haeinorrhoidal  Artery.  6,  Superior  Mesenteric  Artery.  7,  .Middle  Colic  Artery  .nn.istomosing  with 
the  left  and  the  right  (8)  Colic  Arteries.  9.  Branches  to  the  small  Intestine.  10,  Left  Eenal  Artery. 
a,  Small  Intestine  turned  to  the  right  side,    b,  Large  Intestine,    c,  Pancreas. 

The  Superior  Hsemorrlioidal  artery  cannot  well  be  ex- 
amined until  the  arteries  of  the  pelvis  have  been  dissected. 
If  we  suppose  the  rectum  divided  into  three  stages, — a  supe- 
rior, middle,  and  inferior, — we  find  that  in  the  superior  stage 

it  is  surrounded  with  peritoneum,  and  has  a  meso-rectum ;  in 

23 


266  HEMORRHOIDAL   ARTERIES. 

the  middle  stage  it  has  no  meso-rectum,  but  is  covered  by 
peritoneum  upon  its  anterior  part,  and  on  a  portion  of  its 
sides:  in  the  inferior  stage  it  has  no  peritoneal  covering. 
Now,  we  find  the  artery  distributed  in  conformity  with  this 
arrangement ;  for  in  the  first  of  these  stages  it  descends  as  a 
single  trunk  between  the  layers  of  the  meso-rectum ;  it  then 
divides,  about  four  inches  from  the  anus,  into  two  branches ; 
and  these,  in  the  second  stage,  follow  (one  on  either  side)  the 
line  of  reflection  of  the  peritoneum  from  the  side  of  the 
rectum;  lastly,  in  the  third  stage  the  terminating  branches 
of  the  artery  are  numerous,  and  distributed  all  round  the 
inferior  extremity  of  the  intestine.  The  superior  haemor- 
rhoidal  artery  communicates  freely  with  the  haemorrhoidal 
branches  of  the  internal  iliac  and  pudic  arteries. 

In  case  of  hemorrhage  into  the  rectum  from  the  haemor- 
rhoidal arteries,  a  membranous  tube  closed  at  one  end  may 
be  introduced  into  the  rectum,  and  through  the  other  cold 
water  may  be  injected  with  a  syringe,  so  as  to  distend  it,  and 
thus  compress  the  bleeding  vessels  on  the  surface  of  the  gut. 
The  water  can  be  occasionally  renewed  without  withdrawing 
the  tube.  Or,  which  is  preferable,  as  in  the  case  of  hemor- 
rhage after  the  operation  for  fistula  in  ano,  or  after  the  ex- 
cision of  haemorrhoidal  tumors,  a  small  fine  linen  bag,  open 
at  one  end,  and  provided  with  tapes,  may  be  introduced  into 
the  rectum,  and  through  the  external  or  open  extremity  a 
quantity  of  charpie  may  be  introduced,  so  as  to  distend  the 
bag ;  the  tapes  may  be  then  tied  across  the  stufiing  of  charpie, 
and  the  dressing  secured :  the  necessary  compression  on  the 
bleeding  vessels  of  the  intestines  will  be  thus  eff'ected. 

The  liver,  stomach,  spleen,  and  intestines  may  now  be  ex- 
amined and  removed,  after  which  the  student  may  proceed 
with  the  dissection  of  the  deeper  arteries  within  the  cavity  of 
the  abdomen. 

The  Proper  Phrenic  Arteries,  called  also  the  inferior 


PHRENIC   AND    MIDDLE   CAPSULAR   ARTERIES.         267 

phrenic  or  sub-phrenic,  are  the  first  branches  of  the  abdomi- 
nal aorta;  they  arise  immediately  above  the  coeliac  axis,  from 
the  front  of  the  vessel.  The  artery  on  the  right  side  passes 
upward,  forward,  and  outward,  between  the  right  crus  of  the 
diaphragm,  which  lies  behind  it,  and  the  inferior  cava,  which 
is  in  front :  that  of  the  left  side  takes  a  similar  direction, 
separating  the  left  crus  of  the  diaphragm  from  the  oesophagus. 
Having  arrived  at  the  posterior  extremity  of  the  cordiform 
tendon  of  the  diaphragm,  each  artery  communicates  behind 
this  tendon  with  its  fellow  of  the  opposite  side,  and  then 
divides  into  external  and  anterior  branches ;  these  ramify  in 
the  substance  of  the  diaphragm,  and  inosculate  with  the  other 
arteries  which  supply  this  muscle.  The  artery  of  the  right 
side  sends  branches  to  the  liver  through  its  coronary  ligament, 
and  that  of  the  left  side  sends  a  branch  to  the  oesophagus. 
The  external  branches  anastomose  with  the  intercostal  arteries; 
and  the  anterior  branches  communicate  with  the  internal 
mammary,  and  with  the  branches  of  the  opposite  side,  in 
front  of  the  cordiform  tendon :  in  this  manner  there  is  a  kind 
of  arterial  circle  formed  around  this  tendon. 

Soon  after  its  origin,  the  inferior  phrenic  gives  off  the  supe- 
rior  capsular  artery ^  to  supply  the  upper  portion  of  the  supra- 
renal capsule. 

The  Middle  Capsular  Arteries  are  usually  two  in 
number,  viz.  one  on  each  side:  they  arise  from  the  aorta  a 
little  above  the  renal.  Each  of  them  proceeds  transversely 
outwards,  to  arrive  at  the  concave  margin  of  the  correspond- 
ing supra-renal  capsule,  and  divides  into  a  number  of  branches 
which  ramify  in  the  sinuosities  on  its  anterior  and  posterior 
surfaces,  and  in  its  interior.  In  this  course  it  gives  a  few 
branches  to  the  pillars  of  the  diaphragm,  to  the  psoas  muscle, 
and  to  the  adipose  and  areolar  tissue  in  the  neighborhood. 

The  Renal  Arteries  are  two  in  number,  one  on  each 


268 


ABDOMINAL  AORTA. 


Fig.  39.— 27ic  Abdominal  Aorta  and  its  deep  Branches. 


A,  Abdominal  Aorta  between  the  Pillars  of  the  Diaphragm.  B,  Coeliao  Axis,  dividing  into  the 
Gastric,  Hepatic,  and  Splenic  Arteries.  C,  Superior  Mesenteric  Artery,  cut.  D,  D,  Renal  Arteries. 
E,  E,  Common  Iliac  Arteries.  P,  F,  External  Iliac  Arteries.  G,  G,  Internal  Iliac  Arteries,  a,  a, 
Inferior  Phrenic  Arteries,  b,  b,  Superior  Capsular  Arteries,  c.  c.  Middle  Capsular  Arteries,  d,  d, 
Spermatic  Arteries,  e,  Inferior  Mesenteric  Artery,  f,  f,  f.  Lumbar  Arteries  of  right  side,  g,  Middle 
Sacral  Artery,  h,  h.  Internal  Circumflexoe  Ilii  Aneries,  1,  Epigastric  Artery.  K,  Vas  Deferens. 
1,  Internal  Abdominal  Ring.  1,  Xiphoid  Cartilage  or  Appendix.  2.  3,  4,  Diaphragm.  5,  Opening 
for  Inferfor  Cava.  6,  CEsophageal  Openincr.  7,  Union  of  the  Pillars.  8,  9,  Pillars  of  the  Diaphragm. 
10,  10,  Supra-Renal  Capsules.  11,  11,  The  Kidneys.  12,  12,  Pelvis  of  the  Kidney.  13,  13,  Psoas 
Magnus  Muscles.  14,  14,  Quadratus  Lumborum.  15,  15,  Internal  Iliac  Muscle.  16,  Promontiii-y  of 
the  Sacrum.  17,  Rectum.  18,  Urinary  Bladder.  19,  Peritoneum.  20,  Left  Rectus  Muscle.  21, 
Aponeurosis  over  left  Transverse  Muscle. 


RENAL   ARTERIES.  269 

side :  they  arise  from  the  aorta  opposite  to  about  the  second 
lumbar  vertebra,  inferior  and  close  to  the  origin  of  the  supe- 
rior mesenteric :  sometimes  the  left  arises  a  little  higher  than 
the  right.  After  their  origin,  each  of  them  proceeds  at 
nearly  a  right  angle  towards  the  corresponding  kidney.  The 
right  renal  artery  is  longer  than  the  left,  on  account  of  having 
its  origin  on  the  left  side  of  the  spine;  posteriori}/  it  rests  on 
the  spine,  right  sympathetic  nerve,  and  psoas  muscle;  ante- 
riorly it  is  covered  by  the  left  renal  vein,  the  inferior  cava, 
and  the  right  renal  vein :  thus  it  is  nearly  covered  by  these 
veins  in  its  entire  course,  so  that  without  disturbing  these 
vessels  a  very  small  portion  only  of  the  artery  can  be  seen. 
Its  branches,  four  or  five  in  number,  penetrate  the  pelvis  of 
the  kidney  between  the  branches  of  the  vein  which  are  in 
front,  and  the  ureter  which  is  posterior  and  inferior.  The 
left  renal  artery  lies  on  a  small  portion  of  the  psoas  muscle 
covered  by  its  corresponding  vein :  the  branches,  however,  do 
not  enter  the  kidney  behind  the  veins,  as  they  do  usually  on 
the  right  side,  but  frequently  they  are  situated  in  front  of  the 
branches  of  the  left  renal  vein :  in  the  hilus  of  both  kidneys 
the  ureter  lies  posterior  and  inferior  to  the  blood-vessels. 

The  Renal  Veins,  called  also  the  emulgent  veins,  are  two 
large  vessels  which  escape,  one  from  the  hilus  of  each  kidney. 
The  right  renal  vein  is  shorter  than  that  of  the  left,  in  conse- 
quence of  the  vena  cava  lying  close  to  the  right  kidney ;  and 
it  runs  in  a  more  oblique  direction  than  the  vein  of  the  left 
side,  because  the  right  kidney  is  situated  lower  down  than  the 
left.  The  left  renal  vein  is  longer  and  takes  a  more  trans- 
verse course  than  the  right;  it  crosses  in  front  of  the  aorta 
and  the  spine  in  order  to  reach  the  left  side  of  the  inferior 
vena  cava;  and  in  this  part  of  its  course  it  lies  behind  the 
third  portion  of  the  duodenum.  Sometimes  instead  of  passing 
in  front  of  the  abdominal  aorta,  it  passes  behind  it :  this  vein 
receives  the  contents  of  the  spermatic  vein  of  the  left  testicle. 

23* 


270 


BRANCHES   OF   RENAL   ARTERIES. 


The  branches  given  oflF  by  the  renal  arteries  are,  first, 
inferior  capsular  branches  to  the  supra-renal  capsules ; 
secondly,  hranches  to  the  surrounding  areolar  tissue  and  adi- 

Fig.  40. — Microscopical  Anatomy  of  Kidney.    Represents  the  Arrangement  of  the 
Vessels  in  the  Malpighian  Tufts — after  Bowman. 


A,  Arterial  Branch,  with  its  snbdivirions.  At  a,  the  Capsule  is  ruptured,  and  only  some  of  the 
Vessels  are  seen.  At  d,  the  vessels  are  well  filled,  and  the  injection  passed  out  through  the  efferent 
vessel  cf.  Ate,  h,  the  injection  has  extra%'asat«d.  and  passed  along  the  tube,  ef.  Efferent  Vessel, 
m,  HI,  The  injection,  on  escaping  into  the  capsule,  has  not  spread  over  the  whole  tuft,  t,  t,  t,  Url- 
niferous  Tubes. 


pose  membrane;  thirdly,  a  small  branch  or  two  to  the  ureter, 

and,  lastly,  terminating  branches.    The  terminating  hranches 

are  disposed  of  in  the  manner  which  we  shall  now  describe. 

Arrangement  of  the  vessels  in  the  kidney. — Within    the 


MICROSCOPICAL   ANATOMY   OF   KIDNEY.  271 

hilus  or  notch  in  the  kidney  the  terminating  branches  first 
pass  between  the  calyces,  and  then  run  in  straight  lines  be- 
tween the  cones  of  the  tubular  structure  till  they  arrive  at 
the  cortical  structure  of  the  organ.  In  the  tubular  portion, 
according  to  Mr.  Toynbee,  the  minute  arteries  "  are  arranged 
in  bundles  in  the  shape  of  elongated  cones  whose  bases  are 
continuous  with  the  cortical  portion,  and  their  apices  directed 
towards  the  inammillary  processes."*  When  these  minute 
arteries  have  entered  the  cortical  structure  of  the  kidney, 
most  of  them  terminate  in  forming  small  tu/ts  of  capillary 
vessels  in  the  Malpigliian  corpuscles.  These  bodies  have  been 
described  by  Mr.  Bowmanf  as  being  formed  in  the  first 
instance  by  a  capsule  which  consists  of  an  expansion  of  the 
dilated  commencement  of  a  urinary  tubule;  through  this 
capsule  a  minute  artery  passes,  called  vas  infer  ens,  which, 
after  arriving  within  it,  subdivides  into  several  minute  ca- 
pillary branches,  which  form  a  number  of  vascular  loops 
closely  bound  up  together  within  the  capsule,  sq  as  to  form  a 
tuft :  from  this  tuft  of  vessels  a  small  vein  takes  its  origin, 
vas  efferens,  which  escapes  from  the  inner  portion  of  the 
corpuscle,  passes  through  the  capsule  and  joins  a  plexus  of 
veins,  formed  of  several  efferent  veins,  which  are  situated  be- 
tween the  Malpighian  corpuscles,  and  surround  the  small  con- 
voluted tubuli  uriniferi  immediately  after  their  origin  :  these 
capillary  veins  terminate  in  the  formation  of  the  i-enal  vein. 
Mr.  Bowman  describes  a  number  of  minute  capillary  arteries 
which  do  not  go  to  the  Malpighian  corpuscles,  but  which  en- 
velope the  convoluted  tubes  and  communicate  directly  with 
the  veins.  According  to  Mr.  Bowman,  the  capsule  of  the 
Malpighian  body  consists  of  the  dilated  origin  of  the  urinife- 
rous  tubule ;  whilst,  according  to  Mr.  Toynbee,  this  capsule 
consists  of  a  structure  totally  distinct  from  the  tubule,  and 
which  surrounds  the  convoluted  origin  of  the  tubule  in  con- 

*  Med.  Ch.  Trans.,  vol.  xxix.,  1846. 
t  Phil.  Trans.,  1842. 


272  SPERMATIC   ARTERIES. 

junction  with  the  arterial  tuft  and  the  commencement  of  the 
efferent  vein. 

In  the  early  period  of  intra-uterine  life,  the  kidney  is 
formed  of  a  number  of  independent  lobules,  each  supplied 
with  a  distinct  set  of  vessels ;  and  even  in  the  adult  there 
remains  so  much  distinction,  that  different  compartments  of 
the  kidney  can  be  injected  of  different  colors. 

FigAl. — Represents  two  Malpighian  Bodies  injected.  Tlie  tufts  are  burst,  and  the 
fluid  has  escaped  into  the  capsule.  In  one  case  it  has  passed  also  along  the  tube,  the 
tortuosity  of  which,  at  its  commencement,  is  well  seen.-^J/ler  Bowman. 


A,  Arterial  Branch,  a,  f,  Arterial  Twigs  or  Afferent  Vessels  of  the  Malpighian  Tufts,  c,  c, 
Malpighian  Bodies,  distended,  d,  e,  The  Depression  sometimes  seen  where  the  Afferent  and 
Efferent  Vessels  pass,    t,  Uriuiferous  tube. 

The  Spermatic  Arteries  arise  from  the  front  of  the 
aorta  a  little  beneath  the  renal :  each  of  them  descends  ob- 
liquely outwards,  lying  anterior  to  the  psoas  muscle  and  ureter, 
which  latter  it  crosses  at  an  acute  angle.  On  the  right  side, 
the  spermatic  artery  crosses  also,  obliquely,  the  front  of  the 
vena  cava  inferior;  sometimes,  however,  it  goes  behind  it. 
On  the  left  side  the  artery  passes  behind  the  sigmoid  flexure 
of  the  colon.  In  this  course  the  spermatic  veins  lie  to  the 
outside  of  the  corresponding  arteries,  and  the  peritoneum 
covers  them  in  front :  sometimes  we  may  find  two  spermatic 


SPERMATIC   VEINS.  273 

• 

veins,  one  lying  at  either  side  of  the  artery  and  communi- 
cating in  front  of  it  by  numerous  small  transverse  branches. 
In  the  rest  of  their  course  the  spermatic  arteries  differ  in  the 
male  and  in  the  female  subject. 

In  the  male,  the  spermatic  artery  enters  the  inguinal  canal, 
and  descends  on  the  front  of  the  vas  deferens,  forming  part 
of  the  spermatic  cord,  and  becoming  extremely  tortuous  as  it 
approaches  its  termination  :  a  little  above  the  testis  it  divides 
into  two  branches,  one  of  which  enters  the  head  of  the  epi- 
didymis, while  the  other  penetrates  the  superior  margin  of 
the  body  of  the  testis,  and  repairs  to  the  corpus  Highmori- 
anum,  from  whence  they  both  issue  in  two  sets :  one  set  rami- 
fies on  the  internal  part  of  the  tunica  albuginea,  and  detaches 
minute  vessels  at  various  points  to  the  tubuli  testis,  around 
which  they  coil ;  the  other  set  pierces  the  corpus  Highmori- 
anum,  and  descends  along  the  septa  of  the  testicle  from  its 
posterior  to  its  anterior  margin. 

Sir  A.  Cooper  describes  the  tunica  albuginea  as  having 
two  layers, — an  outer  one  analogous  to  the  dura  mater,  and  an 
inner  one  (in  which  the  vessels  ramify)  analogous  to  the 
pia  mater.  Cruveilhier  dissents  from  this  description,  and 
thinks  that  "the  vessels  contained  in  the  tunica  albuginea 
rather  resemble  the  sinuses  of  the  dura  mater  than  the  vas- 
cular net-work  of  the  pia  mater." 

In  the  female,  the  spermatic  artery  turns  inwards  over  the 
common  iliac,  and  passes  to  the  side  of  the  uterus,  between 
the  layers  of  the  peritoneum  composing  its  broad  ligament : 
it  supplies  the  ovary,  Fallopian  tube,  and  uterus,  and  anasto- 
moses with  the  proper  uterine  arteries.  In  pregnancy,  the 
branches  to  the  uterus  become  enormously  large  and  tortuous. 

The  Veins  which  accompany  the  spermatic  artery  arise 
from  the  testis  and  epididymis,  and  form  a  plexus  immediately 
after  their  junction.  They  then  ascend,  four  or  five  in  num- 
ber, through  the  inguinal  canal,  lying  in  front  of  the  vas 
deferens,  and  ultimately  unite,  in  the  lower  part  of  the  lum- 


274 


SPERMATIC   ARTERIES. 


bar  region,  into  a  single  trunk  wtich  ascends  on  the  outside 
of  the  spermatic  artery.  The  right  spermatic  vein  empties 
its  contents  into  the  inferior  vena  cava,  with  which  it  forms 
an  acute  angle  below  the  termination  of  the  right  renal.    The 


Fig.  4:2.— Represents  the  Arteries  of  the  Uterus  in  a  Female  wlio  died  six  days  after 
delivery. 


A,  Abdominal  Aorta.  B,  Superior  Mesenteric  Artery,  divided.  C.  C,  Renal  Arteries.  D,  InfO' 
rior  Mesenteric  Artery,  cut.  E,  E,  Common  Iliac  Arteries.  F,  F,  External  Iliac  Arteries.  G,  O, 
Internal  Iliac  Arteries,  a,  a,  a.  Spermatic  Arteries,  greatly  convoluted  and  enlarged  at  their 
termination,  b,  b,  b,  b,  b,  Lumbar  Arteries,  c.  Middle  Sacral  Artery,  d,  d,  d,  d,  Uterine  Arte- 
ries, convoluted  and  enlarged,  e,  e,  Internal  Circunittexoe  Ilii  Arteries,  f.  f,  Anastomosis  between 
Iliolumbar  and  CircumtlexaB  Ilii  Arteries.  1,  1,  Kidneys.  2,  2,  Pelves  of  the  Kidneys.  3,  3, 
Quadratus  Lumborum  Muscle  of  each  side.  4,  4,  Psoas  Parvus.  5,  5,  Psoas  Magnus.  6,  6,  Iliacus 
Internus.  7,  7,  Anterior  Superior  Iliac  Spine.  8,  8,  Crural  Arch.  9,  Promontory  of  Sacrum. 
10,  Rectum.    11,  Uterus  turned  forward.    12, 12,  The  ovaries.    13,  13,  The  Fallopian  Tubes. 


left  spermatic  vein  empties  itself  into  the  left  renal,  with 
which  it  forms  nearly  a  right  angle.  In  many  cases  the 
spermatic  vein  divides  at  a  short  distance  above  the  gland, 
into  many  branches,  so  as  to  form  a  peculiar  plexus,  termed 


LUMBAR   ARTERIES.  275 

the  pampiniform  plexus;  after  which  it  again  becomes  a 
single  trunk.  Meckel  says  that  the  plexus  exists  more  fre- 
quently on  the  left  side  than  on  the  right. 

As  the  left  testicle  is  lower  than  the  right,  the  veins  are 
longer;  and  this  (together  with  the  peculiar  mode  of  ter- 
mination of  the  left  spermatic  vein,  and  its  relation  to  the 
sigmoid  flexure  of  the  colon)  is  supposed  to  explain  why  a 
varicose  state  of  these  vessels  is  more  frequent  on  the  left 
than  on  the  right  side. 

In  the  male  foetus  these  arteries  are  proportionably  very 
short,  as  the  testicles  are  placed  within  the  abdomen  during 
the  greater  part  of  intra-uterine  life ;  but  they  subsequently 
elongate  as  the  testicles  descend.  The  spermatic  arteries  are 
remarkable  for  increasing  in  diameter  as  they  recede  from 
their  origin.  In  the  operation  of  castration,  the  spermatic 
artery  is  apt  to  contract  considerably  on  being  divided,  so  as 
to  render  it  difficult  to  secure  it  in  a  ligature.  The  surgeon 
may  avoid  this  embarrassment  by  holding  the  divided  cord 
in  his  hand  till  an  assistant  draws  out  and  secures  whatever 
branches  are  necessary.  The  exquisitely  painful  practice 
of  including  the  cord  in  the  ligature  is  now  universally 
abandoned. 

The  Lumbar  Arteries  are  generally  four  in  number  on 
each  side;  sometimes,  however,  we  meet  five,  and  sometimes 
only  three.  They  are  larger  than  the  intercostal,  to  which 
they  are  analogous.  Each  of  them  arises  from  the  posterior 
and  lateral  part  of  the  aorta,  and  passes  outwards  on  the  body 
of  the  corresponding  vertebra,  and  then  behind  the  sympa- 
thetic nerve  and  psoas  muscle  :  those  that  are  sufficiently  high 
pass  also  behind  the  corresponding  pillar  of  the  diaphragm. 
The  upper  ones  are  also  more  nearly  horizontal;  while  the 
lower  descend  with  a  gradually  increasing  obliquity.  Opposite 
the  corresponding  transverse  process,  each  of  them  divides 
into  an  anterior  and  posterior  branch. 


276  MIDDLE  SACRAL  ARTERY. 

The  anterior  hranch,  smaller  than  the  posterior,  passes  out- 
wards between  the  psoas  and  quadratus  lumborum  muscles, 
and  then  between  the  quadratus  and  anterior  layer  of  the 
transversalis  tendon.  The  anterior  branch  of  the  first  lumbar 
passes  outwards  beneath  the  last  rib,  and  along  the  insertion 
of  the  diaphragm,  and  then  on  front  of  the  quadratus  lum- 
borum: it  communicates  with  the  intercostal  arteries.  The 
anterior  branch  of  the  fourth,  follows  the  attachment  of  the 
quadratus  lumborum  to  the  crest  of  the  ileum,  and  com- 
municates with  the  ilio-lumbar.  All  the  anterior  branches, 
moreover,  communicate  with  the  adjacent  ones,  and  supply 
the  quadratus  lumborum  and  broad  muscles  of  the  abdomen. 

The  posterior  hranch  of  each  lumbar  artery  first  sends  a 
small  vessel  through  the  corresponding  lateral  foramen  into 
the  spinal  canal  to  be  distributed  in  the  spinal  marrow  arid  its 
tunics,  and  afterwards  expends  itself  in  the  lumbar  mass  of 
muscles,  and  the  integuments. 

The  Middle  Sacral  Artery,  usually  smaller  than  the 
lumbar  arteries,  arises  from  the  posterior  part  of  the  aorta  a 
little  above  its  bifurcation ;  it  then  descends  on  the  front  of 
the  spine,  separated  from  it  by  the  anterior  common  ligament; 
and  then  on  the  middle  line  of  the  sacrum,  separated  from  it 
by  the  periosteum  of  that  bone ;  it  is  covered  in  front  by  the 
aorta,  left  common  iliac  vein,  and  by  the  pelvic  viscera.  It 
is  separated  from  the  lateral  sacral  of  either  side  by  the  cor- 
responding trunk  of  the  sympathetic  nerve.  Inferiorly  it 
terminates  by  dividing  into  two  branches,  right  and  left, 
which  communicate,  in  the  form  of  a  double  arch,  with  the 
right  and  left  lateral  sacral  arteries.  Opposite  each  bone  of 
the  sacrum  this  artery  sends  off  transverse  branches  to  either 
side,  which  supply  the  periosteum,  and  communicate  with  the 
lateral  sacral  and  hsamorrhoidal  arteries. 

COMMON    ILIAC    ARTERIES. 

On  the  left  side  of  the  fourth  lumbar  vertebra,  or  corre- 


RIGHT   COMMON   ILIAC   ARTERY.  277 

spending  to  the  intervertebral  substance  between  the  fourth 
and  fifth  (and  nearly  opposite  the  left  margin  of  the  umbilicus), 
the  aorta  bifurcates  into  the  right  and  left  common  iliac 
arteries.  These  large  vessels  vary  in  length  from  two  to  three 
inches :  they  diverge  as  they  descend,  leaving  an  angle 
between  them,  wider  in  the  female  than  in  the  male. 

The  Right  Common  Iliac  Artery  descends  obliquely  to  the 
right  side,  till  it  reaches  the  superior  extremity  of  the  sacro- 
iliac symphysis.  Its  posterior  surface  in  this  course  lies  on 
the  cartilage  between  the  fourth  and  fifth  lumbar  vertebrae; 
on  the  body  of  the  last-named  vertebra,  and  on  the  anterior 
common  ligament  which  is  interposed  between  these  parts 
and  the  artery :  it  then  lies  on  the  bifurcation,  or,  more 
properly  speaking,  on  the  commencement  of  the  inferior  vena 
cava,  and  consequently  on  both  the  left  and  right  common 
iliac  veins  as  they  unite  to  form,  by  their  conflux,  the  origin 
of  this  large  vein.  In  fact,  almost  immediately  after  its  origin 
the  right  common  iliac  artery  is  borne  off  the  spine  by  the 
large  veins  which  lie  behind  it.  Its  right  or  corresponding 
vein  not  only  lies  behind  it,  but  projects  above  to  its  outside, 
whilst  lower  down,  part  of  the  vein  appears  on  its  inner  side : 
the  sympathetic  nerve,  and  still  more  deeply  seated  the  obtu- 
rator nerve,  descend  behind  it  into  the  pelvis.  We  may 
observe  a  deep  groove  situated  between  the  inner  edge  of  the 
psoas  magnus  and  the  spine,  and  it  is  in  this  groove  that  we 
expose  the  obturator  nerve  :  by  continuing  our  dissection  still 
deeper  in  this  locality  we  come  upon  the  lumbo-sacral  nerve 
on  its  way  into  the  pelvis,  and  upon  the  lumbar  division  of 
the  ilio-lumbar  branch  of  the  internal  iliac  artery.  Its 
anterior  surface  is  covered  by  the  peritoneum ;  it  is  crossed 
obliquely  at  its  bifurcation  into  the  internal  and  external 
iliac  arteries,  by  the  ureter ;  and  it  is  covered  by  the  last  coil 
of  the  ileum,  as  it  ascends  from  the  true  pelvis  to  join  the 
caecum  in  the  right  iliac  fossa.     In  the  female  the  spermatic 

vessels  turn  over  it  to  reach  the  uterus. 

24 


278  LIGATURE   or   THE   COMMON   ILIAC. 

The  Left  Common  Iliac  Artery  descends  with  less  obliquity 
than  the  right,  and  is  usually  shorter,  in  consequence  of  the 
aorta  bifurcating  on  the  left  side  of  the  spine.  In  many 
cases,  however,  it  will  be  found  longer,  that  is,  the  artery  of 
the  right  side  will  bifurcate  into  its  two  terminating  branches 
before  it  reaches  the  right  sacro-iliac  synchondrosis;  whilst 
the  left  continues  its  course  until  it  reaches  this  point  at  the 
left  side :  this  fact,  we  believe,  was  first  pointed  out  by  Mr. 
Adams,  of  this  city.  Its  posterior  surface  rests  on  the  outer 
portion  of  the  anterior  common  ligament,  the  fifth  lumbar 
vertebra,  and  on  the  outer  edge  of  its  corresponding  vein : 
the  sympathetic,  obturator  and  lumbo-sacral  nerves  also  descend 
behind  it  as  on  the  other  side.  Its  anterior  surface  is  covered 
by  the  peritoneum,  and  crossed  obliquely  by  the  ureter  at  its 
bifurcation ;  it  is  covered  also  by  the  sigmoid  flexure  of  the 
colon  and  the  termination  of  the  inferior  mesenteric  artery. 
In  the  female,  the  vessels,  analogous  to  the  spermatic,  are 
also  related  to  it.  It  may  be  observed  that  the  vein  on  this 
side  is  in  no  part  of  its  course  external  to  the  artery,  as  on 
the  opposite  side.  The  psoas  muscles  are  situated  on  the  out- 
side of  the  common  iliacs,  and  between  the  two  we  see  the 
middle  sacral  artery  and  part  of  the  common  iliac  vein  of 
the  left  side. 

The  common  iliac  arteries  give  off  no  branches  before  their 
bifurcation,  except  very  minute  ones  to  the  ureters,  perito- 
neum, iliac  veins,  and  adjacent  lymphatic  glands.  The  com- 
mon iliacs  vary  in  their  length,  and  bifurcate  usually  near  the 
sacro-iliac  symphysis  into  the  external  and  internal  iliac 
arteries. 

Operation  of  tying  the  Common  iliac  artery. — The  opera- 
tion of  tying  the  common  iliac  artery  has  been  performed 
upwards  of  twenty  times  on  the  human  subject;  first,  by  Dr. 
Wm.  Gibson,  of  Philadelphia,  in  1812,  in  a  case  of  gun-shot 
wound;  the  patient  died  from  hemorrhage  in  thirteen  days 
after  the  operation  :  it  was  tied  in  March,  1827,  by  Valentine 


ILIAC    AND    FEMORAL   ARTERIES. 


279 


Fig.  43 — Represents  the  Surgical  Anatomy  of  the  Iliac  and  Femoral  Arteries. 


A,  Bifurcation  of  the  Abdpminal  Aorta.  B,  The  Anterior  Superior  Iliac  Spine.  C,  Bifurcation  of 
left  common  Iliac  Artery.  D,  Poupart's  Ligament.  E,  R*,  Tlie  right  and  left  Iliao  Muscles,  with 
the  Inferior  Musculo-  or  Inguino-Cutaneous  Nerve  of  each  side.  P,  The  Inferior  Veua  Cava.  G, 
Bifurcation  of  the  right  Common  Iliac  Artery.  H,  H*,  The  right  and  left  Common  Iliac  A'eius. 
I,  I*,  The  right  and  left  External  Iliac  Arteries,  each  crossed  by  the  Circumflexa  Ilii  Vein.  K,  K*, 
The  right  and  left  External  Iliac  Veins.  L,  The  Urinary  Bladder,  covered  by  Peritoneum.  M,  The 
Rectum,  divided  and  tied.  N,  The  Profunda  Branch  of  the  Femoral  Artery.  O,  The  Femoral  Vein ; 
o,  the  Saphena  Vein.  P,  The  Anterior  Crural  Nerve.  Q,  The  Sartorius  Muscle,  cut.  R,  The  Rec- 
tus Muscle.  S,  Pectineus  Muscle.  T,  The  Adductor  Longus.  U,  The  Gracilis  Muscle.  V,  The  Open- 
ing or  Entrance  into  Hunter's  Canal,  with  the  strong  Fibrous  Structure  given  off  by  the  Adductor 
Longus  to  the  Vastus  luteraus.    g,  g,  The  right  and  left  Ureters. 


280  MR.  mott's  case. 

Mott,  of  New  York;  and  in  the  year  following  by  Sir  P. 
Crampton  in  this  city.  It  has  also  been  tied  by  Salamon, 
Liston,  Guthrie,  Syme,  Deguise,  Perigof,  Post,  Stevens,  Peace, 
Stanley,  Hey,  and  Lyon.  Out  of  all  these  cases  nearly  two- 
thirds  of  them  terminated  successfully.  Mott's  case  was  suc- 
cessful ;  and  as  it  contains  a  great  deal  of  important  and  in- 
teresting information,  we  shall  detail  it  at  length. 

Mr.  Motfs  Case. — The  subject  of  this  operation,  Isaac 
Crane,  aged  33,  was  a  man  of  temperate  habits,  and  his 
disease  was  a  large  aneurismal  tumor,  of  nearly  three  months' 
standing ;  filling  the  iliac  fossa,  and  extending  from  a  little 
above  Poupart's  ligament,  to  near  the  umbilicus. 

"  The  patient  being  placed  upon  a  table  of  suitable  height, 
the  pubes  and  groin  of  the  right  side  being  shaved,  an  in- 
cision was  commenced,  just  above  the  external  abdominal 
ring,  and  carried  in  a  semicircular  direction,  half  an  inch 
above  Poupart's  ligament,  until  it  terminated  a  little'  beyond 
the  anterior  superior  spinous  process  of  the  ilium,  making  it 
in  extent  about  five  inches.  The  integuments  and  superficial 
fascia  were  divided,  which  exposed  the  tendinous  part  of  the 
external  oblique  muscle,  upon  cutting  which,  in  the  whole 
course  of  the  incision,  the  muscular  fibres  of  the  internal 
oblique  were  exposed,  the  fibres  of  which  were  cautiously 
raised  with  the  forceps  and  cut  from  the  upper  edge  of  Pou- 
part's ligament.  This  exposed  the  spermatic  cord,  the  cel- 
lular covering  of  which  was  now  raised  with  the  forceps,  and 
divided  to  an  extent  sufficient  to  admit  the  fore-finger  of  the 
left  hand  to  pass  upon  the  cord,  into  the  internal  abdominal 
ring.  The  finger,  serving  now  as  a  director,  enabled  me  to  divide 
the  internal  oblique  and  transversalis  muscles  to  the  extent 
of  the  external  incision  while  it  protected  the  peritoneum. 
In  the  division  of  the  last-mentioned  muscles,  outwardly,  the 
circumflexa  ilii  artery  was  cut  through,  and  it  yielded,  for  a 
few  minutes,  a  smart  bleeding.  This,  with  a  smaller  artery 
upon  the  surface  of  the  internal  oblique  muscle,  between  the 


MR.  mott's  case.  281 

rings,  and  one  in  the  integuments,  were  all  that  required 
ligatures. 

"With  the  tumor  beating  furiously  underneath,  I  now 
attempted  to  raise  the  peritoneum  from  it,  which  we  found 
difficult  and  dangerous,  as  it  was  adherent  to  it  in  every  di- 
rection. By  degrees  we  separated  it,  with  great  caution,  from 
the  aneurismal  tumor,  which  had  now  bulged  up  very  much 
into  the  incision.  But  we  soon  found  that  the  external  inci- 
sion did  not  enable  us  to  arrive  at  more  than  half  the  extent 
of  the  tumor,  upwards.  It  was  therefore  extended,  upwards 
and  backwards,  about  half  an  inch  within  the  ileum,  to  the 
distance  of  three  inches,  making  a  wound  in  all  about  eight 
inches  in  length. 

"The  separation  of  the  peritoneum  was  now  continued, 
until  the  fingers  arrived  at  the  upper  part  of  the  tumor,  which 
was  found  to  terminate  at  the  going  off  of  the  internal  iliac 
artery.  The  common  iliac  was  next  examined,  by  passing 
the  fingers  upon  the  promontory  of  the  sacrum;  and,  to  the 
touch,  appearing  to  be  sound,  we  determined  to  place  our 
ligature  upon  it,  about  half-way  between  the  aneurism  and 
the  aorta,  with  a  view  to  allow  length  of  vessel  enough  on 
each  side  of  it  to  be  united  by  the  adhesive  process. 

"  The  great  current  of  blood  through  the  aorta  made  it 
necessary  to  allow  as  much  of  the  primitive  iliac  to  remain 
between  it  and  the  ligature  as  possible;  and  the  probable 
disease  of  the  artery,  higher  than  the  aneurism,  required  that 
it  should  not  be  too  low  down.  The  depth  of  this  wound, 
the  size  of  the  aneurism,  and  the  pressure  of  the  intestines 
downwards  by  the  efforts  to  bear  pain,  made  it  impossible  to 
see  the  vessel  we  wished  to  tie.  By  the  aid  of  curved  spa- 
tulas, such  as  I  used  in  my  operation  upon  the  innominata, 
together  with  a  thin  piece  of  board,  about  three  inches  wide, 
prepared  at  the  time,  we  succeeded  in  keeping  up  the  peri- 
toneal mass,  and  getting  a  view  of  the  arteria  iliaca  communis, 
on  the  side  of  the  sacro-vertebral  promontory.     This  required 

24* 


282  MR.  mott's  case. 

great  effort  on  our  part,  and  could  only  be  continued  for  a 
few  seconds.  The  difficulty  was  greatly  augmented  by  the 
elevation  of  the  aneurismal  tumor,  and  the  interruption  it 
gave  to  the  admission  of  light. 

"When  we  elevated  the  pelvis,  the  tumor  obstructed  our 
sight;  when  we  depressed  it,  the  crowding  down  of  the  in- 
testines presented  another  difficulty.  In  this  part  of  the  ope- 
ration I  was  greatly  assisted  by  Dr.  Osborn,  and  my  enter- 
prising pupil  Adrian  A.  Kissam.  Introducing  my  right 
hand,  now,  behind  the  peritoneum,  the  artery  was  denuded 
with  the  nail  of  the  fore-finger,  and  the  needle  conveying  the 
ligature  was  introduced,  from  within  outwards,  guided  by  the 
fore-finger  of  the  left  hand,  in  order  to  avoid  injuring  the 
vein.  The  ligature  was  very  readily  passed  underneath  the 
artery,  but  considerable  difficulty  was  experienced  in  hooking 
the  eye  of  the  needle,  from  the  great  depth  of  the  wound, 
and  the  impossibility  of  seeing  it.  The  distance  of  the  artery 
from  the  wound  was  the  whole  length  of  my  aneurismal 
needle. 

"  After  drawing  the  ligature  under  the  artery,  we  succeeded, 
by  the  aid  of  our  spatulas  and  board,  in  getting  a  fair  view 
of  it,  and  were  satisfied  that  it  was  fairly  under  the  primitive 
iliac,  a  little  below  the  bifurcation  of  the  aorta.  It  was  now 
tied ;  the  knots  were  readily  conveyed  up  to  the  artery  by  the 
fore-fingers:  all  pulsation  in  the  tumor  instantly  ceased. 
The  ligature  upon  the  artery  was  a  very  little  below  a  point 
opposite  the  umbilicus." 

The  wound  was  dressed  in  the  usual  way:  the  operation 
lasted  less  than  an  hour.  It  was  performed  on  the  15th  of 
March,  and  the  ligature  was  removed  from  the  artery  on  the 
3d  of  April  following.  On  the  20th  of  May,  he  made  a 
journey  of  twenty-five  miles.* 

Sir  P.  Crampton's  patient  died  on  the  eleventh  day;  and 

*  Johnson's  Med.  Chir.  Review,  vol.  viii.  1828,  p.  472. 


MR.  key's  case.  283 

the  failure  of  the  operation  has  been  attributed  to  the  employ- 
ment of  a  catgut  ligature,  which  (as  appeared  from  examina- 
tion of  the  body)  either  broke  from  the  impulse  of  the 
blood,  or  had  rotted  away. 

Ml'.  HeyU  Case. — "The  patient,  a  gentleman  aged  forty, 
perceived,  on  the  10th  of  November,  a;  small  hard  tumor  in 
his  left  groin,  above  the  centre  of  Poupart's  ligament.  Three 
days  afterwards  he  had  severe  pain  in  the  part,  and  on  the 
following  day  the  swelling  increased  in  size,  accompanied 
with  pulsation.  It  was  resolved,  in  consultation,  to  apply  a 
ligature  to  the  common  iliac  artery,  which  operation  was  per- 
formed on  December  the  3d.  The  incision  was  begun  two 
inches  and  three-quarters  above  the  navel,  and  three  inches 
from  the  median  line,  and  was  carried  six  inches  downwards 
in  a  semicircular  direction,  with  a  prolongation  of  an  inch 
and  a  half  in  a  straight  line  outwardly.  The  layers  of  muscles 
and  fascia  transversalis  having  been  divided  to  the  whole  ex- 
tent of  the  incision,  the  peritoneum  was  gently  separated  from 
the  parts  beneath,  and  the  common  iliac  artery  was  easily 
reached.  A  little  time  was  occupied  in  scratching  through 
the  sheath  with  the  point  of  the  aneurism-needle,  after  which 
it  was  passed  under  the  artery  from  within  outwards,  armed 
with  a  double  ligature  of  stay-maker's  silk,  and  the  operation 
completed.  The  pulsation  in  the  tumor  ceased  immediately 
after  the  artery  was  tied.  The  tumor  gradually  subsided  in 
size.  A  week  after  the  operation,  pulsation  was  felt  in  the 
anterior  tibial  artery.  On  the  twenty-eighth  day  the  ligature 
was  found  loose  in  the  wound  and  removed.  About  the 
20th  of  January  the  patient  was  free  from  complaint  and 
was  able  to  walk  about."* 

When  the  flow  of  blood  through  the  common  iliac  artery 
is  prevented,  the  internal  mammary  supplies  the  limb  through 
the  epigastric ;  the  inferior  lumbar  arteries  supply  it  through 

*  Med.  Press,  vol.  ii.  p.  299. 


284  INTERNAL   ILIAC   ARTERY. 

the  glutaeal  and  ilio- lumbar;  and  the  internal  iliac  of  the 
sound  side,  through  the  communicating  branches  of  the  in- 
ternal iliac  of  the  diseased  side. 

The  common  iliac  artery  may  be  arrived  at  for  the  purpose 
of  including  it  in  a  ligature,  by  the  proceeding  recommended 
for  tying  the  internal  iliac. 

THE   INTERNAL   ILIAC   ARTERY. 

This  artery  arises  from  the  common  iliac  on  a  plane  pos- 
terior to  the  origin  of  the  external  iliac ;  it  is  from  an  inch 
and  a  half  to  two  inches  in  length  :  in  the  adult,  it  descends 
backwards  and  inwards  in  front  of  the  sacro-iliac  symphysis, 
as  far  as  the  superior  extremity  of  the  great  sacro-sciatic 
notch ;  here  it  becomes  ligamentous,  and  ascends  to  the  um- 
bilicus, on  the  side  of  the  bladder,  being  covered  posteriorly 
by  its  superior  false  ligament.  In  its  first  or  truly  arterial 
stage  it  forms  a  curvature,  the  concavity  of  which  looks  for- 
wards. Its  posterior  or  convex  surface  rests  on  the  sacro- 
iliac symphysis,  from  which  it  is  separated  by  its  correspond- 
ing vein,  which  on  the  right  side  projects  from  underneath 
its  outer  edge ;  and  by  the  lumbo-sacral  nerve,  which  lies  still 
deeper  than  the  vein :  from  behind  it  we  see  also  the  obtu- 
rator nerve  passing  forwards,  and  running  in  the  angle  be- 
tween the  internal  and  external  iliac  arteries.  Its  anterior 
surface  is  covered  by  peritoneum,  and  crossed  superiorly,  at 
its  origin  by  the  ureter,  and  inferiorly  by  the  vas  deferens. 
In  addition  to  these,  the  rectum  covers  the  artery  on  the  left 
side,  and  the  bladder  forms  an  anterior  relation  to  the  internal 
iliac  arteries  of  both  sides. 

The  Internal  iliac  artery  of  the  foetus  presents  for  our  con- 
sideration many  distinct  peculiarities.  First,  it  is  consider- 
ably larger  than  the  external  iliac ;  the  reverse  is  the  fact  in 
the  adult :  in  the  foetus,  it  does  not  descend  deep  into  the 
pelvis,  but  rather  winds  along  the  ilio-pectineal  line,  and  then 
ascends,  not  in  a  ligamentous  form,  but  pervious,  and  carry- 


INTERNAL   ILIAC   ARTERY. 


285 


Fig.  4A.—  View  of  the  left  side  of  the  Pelvis,  the  Bladder,  Uterus,  Vagina,  and 
Rectum,  turned  downward  so  as  to  exhibit  the  distribution  of  the  Internal  Iliac 
Artery. 


1,  Aorta.  2,  Right  Common  Iliac  Artery.  3,  Left  Common  Iliac.  4,  Middle  Sacral.  5,  External 
Iliac.  6,  Circumflex  Iliac.  7,  Epigastric.  8,  Internal  Iliac.  9,  Ilio-Lumbar.  10,  Lateral  Sacral 
Arteries.  11,  (ilutieal  Artery  passing  I'rom  the  Pelvis,  above  the  Pyriform  Muscle,  at  the  upper  part 
of  the  great  Sacro-Sciatic  Foramen.  12,  Superior  Vesical  Artery  ;  the  branch  cut  off  is  extended 
into  the  remains  of  the  Umbilical  Artery.  13,  Obturator  Artery.  U,  Inferior  Vesical  Artery  giving 
off  the  Uteiine  Artery  to  the  Vagina  and  Uteru.s.  15,  Middle  Haemorrhoidal  Artery.  16,  Internal 
Pudic  Artery,  seen  emerging  from  and  again  entering  the  Pelvis.  17,  Ischiatic  Artery,  o.  Iliac 
Muscle.  6,  Psoas  Muscle,  c,  Symphysis  of  the  Pubis,  d.  Sacrum,  e,  Pyriform  Muscle.  /.Internal 
Obturator  Muscle,  o,  Sacro-Sciatio  Ligaments,  ft,  Kectum.  i,  Uterus  and  Vagina,  j.  Fallopian 
Tube,    k,  Bladder. 


286  LIGATURE  OF  INTERNAL  ILIAC. 

ing  blood  from  the  foetus  along  the  sides  of  the  bladder 
through  the  umbilicus  to  the  placenta.  From  the  umbilicus  to 
the  placenta  the  two  arteries  form  part  of  the  umbilical  cord. 

After  birth,  the  internal  iliac  arteries  gradually  diminish, 
and  the  external  iliac  arteries,  and  posterior  or  external 
branches  of  the  internal  iliac,  gradually  enlarge. 

Operation  of  tying  the  internal  Iliac. — The  internal  iliac 
artery  may  require  to  be  tied  in  consequence  of  a  wound,  or 
for  aneurism  of  the  glutaeal  or  other  of  its  branches.  The 
operation  of  tying  it  has  been  performed  in  seven  instances, 
in  four  of  which  it  succeeded.  It  was  first  tried  by  Dr. 
Stevens,  of  Santa  Cruz,  in  the  West  Indies  :  this  patient  re- 
covered.* It  was  afterwards  performed  unsuccessfully,  at  the 
York  Hospital,  by  Mr.  Atkinson.  It  was  also  performed  by 
a  Russian  army  surgeon,  upon  whom  the  Emperor  Alexander 
settled  a  pension  as  a  reward  for  his  dexterity  and  skill. f 
Dr.  White,  of  Hudson,  tied  the  artery  on  a  tailor  aged  sixty 
years  :  in  both  these  latter  cases  the  operation  succeeded.  It 
was  also  tied  by  Mr.  Mott  ]  and  by  Thomas,  of  Barbadoes : 
these  two  patients  died.     It  was  since  tied  by  Mr.  Guthrie. 

In  Dr.  Stevens's  and  3Ir.  Atkinson's  cases  the  operation  in 
each  case  was  commenced  by  an  incision,  five  inches  long, 
through  the  integuments,  fascia,  and  muscles,  parallel  and  a 
little  external  to  the  epigastric  artery. 

Mr.  White  made  a  similar  incision  on  the  side  of  the  ab- 
domen, about  seven  inches  long,  with  its  convexity  to  the 
ilium,  commencing  near  the  umbilicus,  and  terminating  near 
the  inguinal  ring. 

The  remaining  steps,  in  these  cases,  consisted  in  pushing 
inwards  the  sac  of  the  peritoneum  and  carrying  the  finger 
along  the  external  iliac  artery,  until  it  reached  the  origin  of 
the  internal  iliac. 


«-  Med.  Ch.  Trans.,  vol.  v.  p.  422. 
t  Averill's  Operative  Surgery,  p.  55. 


BRANCHES   OP   INTERNAL   ILIAC.  287 

It  is  a  fact  worthy  of  attention  that  the  ureter  is  closely 
connected  to  the  peritoneum,  and  invariably  accompanies  this 
membrane  when  it  is  removed  out  of  the  way  during  the 
operation,  so  that  there  will  be  no  fear  whatever  of  including 
this  duct  within  the  ligature. 

In  order  to  arrive  at  the  internal  iliac  artery,  an  incision 
should  be  made  in  the  direction  of  a  line  extending  from  the 
umbilicus  to  midway  between  the  spine  of  the  pubis  and  the 
anterior  superior  spine  of  the  ilium;  this  incision  should 
commence  at  the  outer  edge  of  the  rectus  muscle,  and  termi- 
nate about  an  inch  above  Poupart's  ligament,  in  order  to 
avoid  the  spermatic  cord.  The  different  muscular  layers  com- 
posing the  anterior  wall  of  the  abdomen  being  successively 
divided,  the  transversalis  fascia  should  be  cautiously  scraped 
through,  and  the  peritoneum  exposed  and  pushed  inwards. 
The  fascia  covering  the  vessels  should  also  be  torn  with  the 
nail,  and  then,  by  following  the  external  iliac  artery  back- 
wards, we  arrive  at  the  internal.  In  the  angle  between  them 
lies  the  external  iliac  vein,  which  should  be  carefully  avoided, 
and  the  needle  introduced  from  within  outwards. 

The  branches  of  the  internal  iliac  artery  are  classed  into 
those  which  remain  within  the  pelvis,  and  those  which  leave 
it  to  be  distributed  externally.  The  latter  are  four  in  num- 
ber, viz.,  the  glutaeal,  sciatic,  pudic,  and  obturator;  and  the 
former,  which  in  the  male  are  five  in  number,  are  the  ilio- 
lumbar, lateral  sacral,  middle  haemorrhoidal,  vesical,  and  um- 
bilical ;  to  which  may  be  added  in  the  female,  the  uterine  and 
vaginal.  We  shall  proceed,  first,  with  the  description  of  the 
external  branches. 

The  branches  of  the  internal  iliac  artery  are  the  follow- 
ing:— 

Branches  supplying  the  parts  outside  the  pelvis. 
Glutaeal.  Sciatic.  Pudic.  Obturator. 


288  GLUTEAL   ARTERY. 

Branches  supplying  the  parts  within  the  pelvis. 


Ilio-lumbar. 

Umbilical :  and,  in  addition, 

Lateral  Sacral. 

in  the  female  J  the 

Middle  Haemorrlioidal. 

Uterine  and  the 

Vesical. 

Vaginal. 

The  Gluteal  Artery  is  the  largest  branch  of  the  inter- 
nal iliac.  It  arises  far  back  in  the  pelvis,  opposite  the  lower 
part  of  the  sacro-iliac  symphysis,  and  immediately  passes 
backwards  between  the  lumbo-sacral  nerve  which  afterwards 
lies  in  front  of  it,  and  first  sacral  nerve  which  lies  behind  it; 
and  above  the  pyriform  muscle,  in  order  to  escape  from  the 
pelvis,  by-  passing  through  the  upper  part  of  the  great  sacro- 
sciatic  notch.  While  within  the  pelvis,  it  gives  oflf  some 
small  branches  to  the  pyriform  muscle,  to  the  rectum,  and  to 
the  areolar  tissue.  After  this  very  short  course,  in  which  it  is 
accompanied  by  the  superior  glutgeal  nerve,  it  divides  oppo- 
site the  posterior  margin  of  the  glutgeus  minimus  muscle,  be- 
tween it  and  the  pyriformis,  and  under  cover  of  the  glutaeus 
maximus,  into  a  superficial  and  a  deep  branch. 

The  superficial  branch  ascends  between  the  glutaeus  maxi- 
mus and  medius,  and  divides  into  numerous  lesser  branches, 
some  of  which  supply  these  muscles  and  the  great  sacro-sciatic 
ligament;  while  others  are  distributed  to  the  sacro-lumbalis 
muscle  and  the  integuments:  some  of  these  branches  commu- 
nicate with  the  sciatic  artery. 

The  deep  branch  takes  a  direction  obliquely  upwards  and 
forwards  between  the  glutseus  medius  and  minimus  muscles. 
After  giving  a  small  nutritious  artery  to  the  ilium,  it  divides 
into  two  lesser  branches;  the  superior  of  which  follows  accu- 
rately the  middle  curved  line  upon  the  bone,  which  marks 
the  upper  margin  of  the  glutsBus  minimus.  This  branch  sup- 
plies, in  its  course,  the  last-mentioned  muscle  and  the  glutaeus 
medius,  and  having  arrived  at  the  anterior  superior  spine  of 
the    ilium,  it  anastomoses  with  the  ilio-lumbar,  circumflexa 


LIGATURE   OP   GLUTEAL   ARTERY.  289 

ilii,  and  external  circumflexa  femoris  arteries.  The  inferior 
hranch  runs  downwards  and  forwards  between  the  two  lesser 
glutaei  muscles,  which  receive  many  branches  from  it,  and  having 
arrived  at  the  great  trochanter,  supplies  the  pyriformis  muscle 
and  capsule  of  the  hip-joint,  and  communicates  with  branches 
of  the  sciatic  and  internal  circumflexa  femoris  arteries. 

Operation  of  tying  the  Glutseal  Artery.  M.  Lizars  gives 
the  following  rule  for  finding  the  trunk  of  the  glutaeal  artery. 
Draw  a  line  from  the  posterior  superior  spinous  process  of 
the  ilium  downwards  to  the  mid-point  between  the  tuberosity 
of  the  ischium  and  the  great  trochanter;  and  then  divide  this 
line  into  three  equal  parts;  the  glutaeal  artery  will  be  found 
emerging  from  the  pelvis  at  the  junction  of  its  upper  and  middle 
thirds.  It  will  rarely  be  necessary,  however,  to  apply  this 
rule,  unless  for  the  purpose  of  avoiding  it  in  opening  deep 
abscesses  of  the  glutaeal  region;  for  in  case  of  a  wound,  we 
must  be  guided  by  the  wound  itself;  and,  in  case  of  glutoeal 
aneurism,  the  surgeon  may  prefer  tying  the  internal  iliac 
artery.  The  opposite  practice  has,  no  doubt,  been  successful : 
thus,  Mr.  Bell  cut  down  on  the  tumor,  in  a  case  of  glutaeal 
aneurism,  opened  the  sac,  and  tied  the  vessel  successfully.* 
Mr.  Carmichael  tied  the  glutaeal  artery  for  a  wound  of  this  vessel 
by  a  pen-knife.  The  following  is  Mr.  Carmichael's  descrip- 
tion of  the  operation: — "The  patient  being  placed  upon  a 
table,  lying  on  his  face,  I  commenced  by  making  an  incision 
five  inches  in  length,  beginning  an  inch  below  the  superior 
posterior  spinous  process  of  the  ilium,  and  about  the  same  dis- 
tance from  the  margin  of  the  sacrum,  and  continued  it  in  a 
line  extending  obliquely  downwards  to  the  trochanter  major. 
The  glutaeus  maximus  and  medius  were  then  rapidly  divided, 
or  rather  their  fibres  separated  (as  the  incision  ran  in  the 
direction  of  the  fibres),  to  the  same  extent  as  that  of  the  in- 
teguments.    The  coagulated  blood  forming  the  tumor  then 


Principles  of  Surgery,  vol.  1.  p.  421. 
23 


290  ARTERIES    OF    THE   PELVIS    AND    THIGH. 

Fig.  45. — Represents  the  Arteries  of  the  posterior  part  of  the  Pelvis  and  Thigh. 


1,  The  Coccyx.  2,  The  Superficial  Sphincter  of  the  Anus.  3,  The  Anus.  4,  The  Scrotum.  5,  The 
Glans  Penis.  6,  fi,  The  Gluteus  Medius  Muscle.  7,  7.  The  Gluteus  Maxitiius.  8,  8,  Kxternal  portion 
of  Vastus  F^xteriius.  9,  9,  Biceps.  10.  10,  The  Seniitcndinosus.  11,  11,  11,  The  Semimembranosus. 
12.  The  Adductor  Magnus.  13,  The  Gracilis.  14,  The  Sartorius.  15,  Small  portion  of  the  A'astus 
Internus.  16,  The  Plantaris.  17,  18,  The  two  heads  of  the  Gastrocnemius.  19,  The  Soleus.  20, 
Branch  from  the  Iliolumbar  Artery.  21,  21,  21.  21,  Branches  of  the  Glut-ieal  Artery.  22,  22,  Twigs 
from  the  Sciatic  Artery.  23,  Twig  from  the  Internal  Pudic  Artery.  24,24,  Branches  of  the  Perforating 
Arteries.  25,  The  Popliteal  Artery.  26,  Muscular  Branch  from  the  Popliteal  Artery.  27,  Superior 
Internal  Articular  Artery.  28,  Superior  External  Articular  Artery.  29,  29,  Sural  Arteries,  proceed- 
ing from  a  common  trunk.  Upper  .30,  Twig  to  Plantaris.  Lower  30,  Branch  to  accompany  the  Posterior 
Saphena  Vein.  31,  31,  Origin  of  the  GlutiBus  Maximus,  cut.  32,  Insertion  of  the  Glutaeus  Maximus, 
cut.  33,  .33,  Origin  of  the  Glutaeus  Medius,  cut.  34,  The  insertion  of  the  Gluteus  Medius,  cut.  35, 
The  Gluteus  Jlinimus.  36,  The  Great  SacroSciatic  Ligament.  37,  The  Pyriformis.  38,  38,  39,  The 
two  Gemelli,  and  Obturator  Internus  between.  40,  Portion  of  Levator  Ani.  41,  Quadratus  Femoris. 
42,  Great  Sciatic  Nerve,  cut.  43,  (Jracilis.  44,  44,  The  Adductor  Magnus.  45,  45,  45,  Long  portion 
of  Biceps  Muscle,  cut.  46,  Shoi*t  portion  of  Biceps  between  the  Vastus  Externus  and  the  Adductors. 
47,  Tendon  of  Biceps.    48,  The  Semi-tendinosus.    49,  The  Bemi -membranosus.    50,  50,  50,  Vastus  Ex- 


SCIATIC   ARTERY.  291 

became  apparent  through  the  sac  or  condensed  cellular  mem- 
brane with  which  it  was  covered.  This  was  divided  the  whole 
extent  of  the  incision  by  running  a  buttoned  bistoury  quickly 
along  the  finger  introduced  into  the  sac,  and  its  contents,  con- 
sisting of  from  one  to  two  pounds  of  coagulated  blood,  were 
emptied  rapidly  out  with  both  hands  into  a  soup-plate,  which 
it  completely  filled.  A  large  jet  of  fresh  blood  instantly  filled 
the  cavity  I  had  emptied ;  but,  the  precise  spot  from  whence 
it  came  being  perceived,  I  was  enabled,  by  pressure  with  the 
finger,  to  prevent  any  further  eff"usion,  while  that  which  had 
been  just  poured  out  was  removed  by  the  sponge.  It  was 
obviously  the  trunk  of  the  glutaeal  artery,  just  as  it  debouches 
from  the  ischiatic  notch,  which  had  been  wounded.  I  endea- 
vored, but  in  vain,  to  secure  the  artery  by  means  of  a  tena- 
culum. I  had  then  recourse  to  a  common  needle  of  large  size, 
and  with  this  instrument  was  immediately  successful  in  passing 
a  Hgature  around  the  bleeding  vessel,  and  in  preventing  all 
further  hemorrhage.  The  ligature  came  away  on  the  sixth 
day,  and  the  patient  recovered."* 

The  Sciatic  or  Ischiatic  Artery,  smaller  than  the 
glutaeal,  descends  on  the  front  of  the  sacral  plexus  of  nerves 
and  pyriformis  muscle :  in  this  course  it  passes  between  the 
rectum  and  outer  wall  of  the  true  pelvis,  and  is  accompanied 
by  the  pudic  artery,  which  is  at  first  somewhat  external  to  it, 
and  then  crosses  in  front  of  it  and  to  its  inside,  opposite  the 
spine  of  the  ischium.  In  company  with  the  pudic  artery, 
and  with  the  greater  and  lesser  sciatic  nerves,  it  escapes  from 

termis.  51,  The  Patella.  52,  The  Ligamentnm  Patellae.  53,  Externa!  Lateral  Ligament  of  Knee  joint. 
54,  The  Plantaris.  55,  55,  55,  The  Gastrocnemius.  56.  56,  The  Soleus.  57.  The  Peroneus  Longus. 
58,  Extensor  Digitorum  Longus.  59,  The  Glutaeal  Artery.  60.  61,  61,  Branches  of  the  Glutaeal  Artery. 
62,  The  Sciatic  Artery.  63,  Coccygeal  Branch  of  the  Sciatic  Artery.  64,  64,  Comes  Nervi  Lschiatici: 
there  are  two  in  this  dissection.  65.  Muscular  Twig  for  Quadratus  Fenioris  and  Gemelli.  66.  Descend- 
ing Branch  of  the  Hamstring  Muscles.  67,  Branch  for  the  Adductors.  68,  69,  70,  70,  External  or  In- 
ferior Haemorrhoidal  Artery  and  Anastomoses.  71,  First  Perforating  Artery.  72,  73,  Anastomosis 
between  the  External  CircuniHex  and  first  Perforating  Artery.  74,  Small  Branch  from  the  first  Per- 
forating Artery,  for  the  Sciatic  N'erve.  75,  75,  75.  Muscular  Twigs  from  first  and  second  Perforating 
Arteries.  76, 'Third  Perforating  Artery.  77,  Popliteal  Artery,  78.  Superior  External  Articular  Artery 
of  Kuee.  79,  79,  79,  Sural  Arteries,  and  Branch  for  Posterior  Saphena  Vein.  80,  Inferior  External 
Articular  Artery  of  Knee.    81,  Branch  from  the  Anterior  Tibial  Recurrent  Artery. 

*  Dublin  Journal,  vol.  iv.  p.  231. 


292  BRANCHES   Or   THE   SCIATIC. 

the  pelvis  through  the  inferior  part  of  the  great  sacro-sciatic 
notch,  passing  between  the  lower  edge  of  the  pyriformis 
muscle  and  the  lesser  sacro-sciatic  ligament.  After  its  exit 
from  the  pelvis  it  is  covered  by  the  gluta3us  maximus  muscle, 
and  is  situated  posterior  and  then  internal  to  the  great  sciatic 
nerve :  it  lies  behind  the  spinous  process  of  the  ischium  near 
its  root,  and  passes  also  behind  the  gemelli,  obturator  internus, 
and  quadratus  femoris  muscles.  While  within  the  pelvis  it 
gives  small  branches  to  the  bladder,  rectum,  uterus,  and  levator 
ani  muscle :  after  it  leaves  the  pelvis,  it  terminates  by  giving 
off  the  following  branches : — 

Muscular.  Comes  Nervi  Ischiatici. 

Coccygeal.  Anastomotic. 

The  Muscular  branches  are  distributed  to  the  glutaeus 
maximus,  quadratus  femoris,  and  hamstring  muscles. 

The  Coccygeal  branch  passes  inwards,  and  in  so  doing  runs 
across  the  posterior  surface  of  the  pudic  artery,  and  then 
passes  between  the  origins  of  the  greater  and  lesser  sacro- 
sciatic  ligaments :  it  supplies  the  glutaaus  maximus,  levator 
ani,  and  coccygeus  muscles,  and  periosteum  of  the  coccyx, 
and  anastomoses  with  the  anterior  spinal  and  with  the  middle 
and  lateral  sacral  arteries. 

The  Comes  Nervi  Ischiatici  at  first  descends  along  the 
internal  margin  of  the  great  sciatic  nerve,  and  then  pene- 
trates its  substance.  Boyer  found  this  branch  as  large  as  the 
radial  at  the  wrist,  in  a  subject  that  Dessault  had  operated  on 
eight  months  before  for  popliteal  aneurism.  I  have  found  it 
in  a  young  child  fully  as  large ;  and  when  it  had  reached  the 
popliteal  space  it  took  the  place  of  the  popliteal  artery :  in 
this  case  the  femoral  artery  was  so  very  small  as  to  be  nearly 
rudimentary. 

The  Anastomotic  branches  unite  at  the  back  of  the  thigh 
with  the  terminating  branches  of  the  internal  circumflex 
from  the  profunda  femoris,  and  with  the  perforating  arteries. 


OBTURATOR   ARTERY.  293 

According  to  Mr.  Lizars,  the  exit  of  the  ischiatic  artery 
from  the  pelvis  may  be  found  by  placing  the  patient  on  his 
face,  with  the  toes  turned  out,  and  drawing  a  line  from  the 
posterior  superior  spine  of  the  ilium,  to  the  fossa  between  the 
tuberosity  of  the  ischium  and  great  trochanter,  but  a  little 
nearer  to  the  former :  the  exit  of  the  artery  will  be  found 
opposite  to  the  centre  of  this  line. 

The  Obturator  Artery.  This  is  the  smallest  and  most 
anterior  of  the  four  branches  of  the  internal  iliac  which  go 
out  of  the  pelvis,  and  should  be  dissected  before  the  pudic. 

Fig.  i:^.— Represents  the  Surgical  Anatomy  of  the  Obturator  Artery,  in  both  its 
Normal  and  Abnormal  Course,  in  connection  with  Femoral^  Hernia. 


A,  Anterior  Superior  Spine  of  the  Ilium.  B.  Symphysis  Pubis.  C,  Tlic  Rectus  Muscle.  D,  Tho 
Peritoneum.  E,  Conjoined  Tendons.  F,  Kpigastiio  Artery.  G,  (r,  Two  different  courses  of  the 
Obturator  Artery,  when  given  off  by  the  Epigastric.  H.  Crural  Ring.  I,  Round  Ligament  of  the 
Uterus.  K,  External  Iliac  Vein.  L.  Kxterual  Iliac  Artery.  M,  Tendon  of  Psoas  Parvus  Muscle, 
resting  on  P.«oas  Magnus.  N.  Uiacus  luternus  Muscle.  O,  Transversalis  fascia.  P.  Cii'cumtlexa 
Ilii  Artery.  Q,  Normal  course  of  Obturator  Artery.  R,  The  Urinary  Bladder.  (See  Varieties  of  the 
Obturator  artery.) 

It  runs  downwards  and  forwards  below  and  within  the  brim 
of  the  true  pelvis,  in  order  to  pass  through  the  upper  part  of 
the  obturator  foramen.  In  this  course  it  is  accompanied  by 
the  obturator  nerve  which  lies  above,  and  the  obturator  vein 
which  lies  beneath  it :  it  communicates  with  the  artery  of  the 

26* 


294  ANO-PERINEAL  REGION. 

opposite  side  by  a  branch  crossing  transversely  behind  the 
body  of  the  pubis.  When  the  obturator  artery  arises  from 
the  epigastric,  its  vein  and  nerve  lie  below  it.  Having 
passed  through  the  obturator  canal,  it  lies  on  the  obturator 
externus  muscle,  covered  by  the  pectineus,  and  there  divides 
into  two  branches,  an  anterior  and  posterior. 

The  Anterior  and  larger  branch  descends  between  the 
adductor  brevis  and  longus  muscles,  and  supplies  these,  as 
well  as  the  obturator  externus,  adductor  magnus,  and  gra- 
cilis muscles.  It  anastomoses  with  the  internal  circumflex, 
and  the  muscular  branches  of  the  femoral  artery.  Some 
of  its  divisions  extend  into  the  perineum,  and  anastomose 
with  the  pudic  artery. 

It  also  detaches  a  small  vessel,  which  descends  along  the 
internal  margin  of  the  obturator  foramen,  to  communicate 
with  the  posterior  branch :  in  this  manner  a  kind  of  arte- 
rial circle  is  formed  around  the  obturator  foramen. 

The  Posterior  branch  descends  along  the  outer  edge  of 
the  obturator  foramen,  towards  the  tuberosity  of  the  ischium, 
passing  between  the  internal  and  external  obturator  muscles : 
it  supplies  the  adjacent  muscles  and  the  capsular  ligament 
of  the  hip-joint:  it  also  sends  a  small  branch  through  the 
notch  in  the  inner  margin  of  the  acetabulum,  to  supply  the 
Haversian  body,  round  ligament,  and  head  of  the  femur. 

Before  commencing  the  dissection  of  the  pudic  artery 
the  student  is  recommended  to  direct  his  attention  to  the 
anatomy  of  the  ano-perineal  region. 

ANO-PERINEAL   REGION. 

For  the  purpose  of  dissecting  this  region,  the  subject 
should  be  placed  in  the  same  position  as  in  that  recom- 
mended for  the  operation  of  lithotomy:  the  hands  should 
be  placed  so  as  to  grasp  the  outer  edges  of  the  feet,  and 
retained  in  this  situation  by  suitable  bandages  :  the  buttock 
being  thus  elevated,  the  rectum  should  be  moderately  dis- 


ANO-PERINEAL   REGION.  295 

tended  with  curled  hair  or  tow,  the  knees  held  apart  from 
each  other,  a  staff  introduced  through  the  urethra  into  the 
bladder,  and  the  scrotum  well  kept  up  towards  the  abdomen. 
The  Ano-perineal  region,  when  fully  exposed,  presents,  in 
its  outline,  the  shape  of  a  lozenge  or  rhomb;  that  is,  the 
appearance  of  two  triangles  united  at  their  bases.  The  a/pex 
of  the  anterior  triangle  corresponds  in  the  middle  line,  ante- 
riorly, to  the  root  of  the  scrotum  superficially,  and  still 
deeper  and  farther  forward  to  the  symphysis  pubis  and  sub- 
pubic ligament.  The  apex  of  the  posterior  triangle  corre- 
sponds posteriorly  to  the  point  of  the  coccyx,  and  to  the 
posterior  attachment  of  the  ano-coccygeal  ligament.  The 
lateral  angles  correspond  to  the  two  tuberosities  of  the  ischia. 
The  four  sides  of  the  region  are  formed,  anteriorly,  by  the 
anterior  portion  of  the  tuberosities  of  the  ischia,  by  the 
ascending  ramus  of  the  ischium  and  descending  ramus  of 
the  pubis  at  each  side  ',  and  posteriorly  at  each  side  by  the 
posterior  portion  of  the  tuberosities  of  the  ischia,  and  by  the 
great  sacro-sciatic  ligament,  overlapped  by  the  glutaeus  max- 
imus  muscle.  A  line  drawn  across  from  one  tuberosity  to 
the  other  would  indicate  the  union  of  the  two  bases  j  this, 
however,  is  merely  an  artificial  arrangement,  as  it  does  not 
accurately  define  the  proper  perineal  from  the  anal  portion 
of  the  region,  since  it  must  pass  across  the  anterior  part  of 
the  anus :  but,  if  the  line  were  made  to  describe  a  curve,  the 
convexity  of  which,  looking  forwards,  would  in  the  middle 
line  pass  anterior  to  the  anus,  such  a  line  would  more  correctly 
define  the  boundary  of  these  two  spaces,  viz.,  the  proper  peri- 
neal and  the  anal,  in  this  situation.  As  we  pursue  the  dissec- 
tion of  this  region,  we  will  find  that  such  a  curved  line  does 
exist,  and  that  it  is  formed  by  the  two  transverse  perinei 
muscles  uniting  in  front  of  the  anus  at  their  insertions  in  the 
central  point  of  the  perineum.  Before  raising  the  integu- 
ments the  student  would  do  well  to  observe  the  appearances 
on  the  surface  of  this  region  : — in  the  middle  line,  anteriorly, 


296  ANO-PERINEAL   REGION. 

he  will  perceive  an  elevation  corresponding  to  the  root  of  the 
scrotum,  and  indicating  the  situation  of  the  hinder  part  of 
the  spongy  portion  of  the  urethra,  and  along  its  centre  an 
elevated  but  narrow  ridge,  known  by  the  name  of  the  raphe 
of  the  perineum :  this  ridge  terminates  posteriorly  at  the 
orifice  of  the  anus.  The  surface  of  the  integument  surround- 
ing this  orifice  is  thrown  by  the  action  of  the  superficial 
sphincter  into  a  number  of  longitudinal  folds,  parallel  with 
the  longitudinal  axis  of  the  intestine.  Behind  this  orifice 
we  remark,  along  the  middle  line,  more  the  appearance 
of  a  groove  than  of  a  ridge,  leading  posteriorly  to  the  point 
of  the  coccyx.  On  either  side  of  the  elevation  which  denotes 
the  situation  of  the  urethra,  we  see  a  groove  or  channel  termi- 
nating posteriorly  along  the  side  of  the  anus,  and  anteriorly 
running  along  the  side  of  the  scrotum  upwards  towards  the 
abdomen.  On  raising  the  integuments  from  off  the  ano-peri- 
neal  region  we  expose  the  superficial  fascia :  this  layer  varies 
in  its  structure  according  to  the  situation  in  which  we  exa- 
mine it :  in  the  perineal  space,  properly  so  called,  it  is  coarse 
and  strong,  and  presents  a  yellowish  color,  and  is  divisible 
into  two  layers,  a  superficial  and  a  deep.  The  superficial 
layer  is  loose  in  its  texture,  containing  a  quantity  of  adipose 
tissue,  the  cells  of  which  are  united  by  areolar  tissue :  the 
deep  layer  is  comparatively  strong  and  membraniform.  There 
is  no  distinction  between  these  two  layers  as  we  pass  into  the 
anal  portion  of  the  region ;  for  corresponding  to  the  inferior 
surface  of  the  transverse  muscles  of  the  perineum  they  become 
identified  with  each  other,  and  are  closely  adherent  to  the 
middle  perineal  fascia  at  the  posterior  margin  of  each  of  these 
muscles,  and  at  the  central  point  of  the  perineum,  in  front  of 
the  anus.  If  we  trace  the  two  layers  of  superficial  fascia 
farther  back,  we  find  them  still  united  into  one  mass,  which 
enters  into  and  fills  up  the  ischio-rectal  spaces,  which  lie  at 
the  sides  of  the  rectum  and  anus.  The  two  layers  of  super- 
ficial fascia  arc  also  intimately  united  with  one  another  cor- 


ANO-PERINEAL   REGION.  297 

responding  to  the  tuberosities  of  the  ischia,  to  -which  they 
become  firmly  adherent ;  and  though  this  membrane  appears 
to  glide  loosely  over  these  prominences,  when  friction  is  exer- 
cised upon  the  integuments,  yet,  if  after  having  removed  the 
skin  we  attempt  to  draw  away  the  fascia  from  the  bone,  we 
find  it  firmly  adherent  to  it.  Along  the  sides  of  the  proper 
perineal  space  we  find  the  superficial  fascia  firmly  adherent  to 
the  ascending  rami  of  the  ischia,  and  descending  rami  of  the 
pubes :  as  we  examine  this  structure  still  more  anteriorly  we 
will  observe,  that,  as  it  becomes  related  to  the  root  of  the 
scrotum  and  to  the  channels  along  its  sides,  the  fascia  loses 
all  its  adipose  tissue,  and  the  entire  substance  becomes  areolar 
in  its  character. 

When,  in  cases  of  extravasation  of  urine,  either  from  lace- 
ration of  the  urethra  from  injury,  or  from  previous  ulceration 
in  the  dilated  portion  of  the  urethra  behind  the  stricture, 
this  fiuid  makes  its  way  to  the  superficial  perineal  fascia,  its 
course  afterwards  is  remarkably  uniform:  in  such  cases  it 
cannot  pass  backwards  between  the  layers  of  the  superficial 
fascia,  because  they  become  firmly  united,  both  at  the  central 
point  of  the  perineum  and  corresponding  to  the  back  part  of 
the  transverse  muscles  of  the  perineum;  neither  can  it  make 
its  way  backwards  between  the  deep-seated  surface  of  this 
fascia  and  the  middle  perineal  fascia,  because  these  fasciae  are 
closely  connected  with  each  other  in  the  situations  just  al- 
luded to.  It  cannot  pass  laterally,  in  consequence  of  the 
close  attachment  which  the  superficial  fascia  takes  to  the 
tuberosities  of  the  ischia,  and  to  the  rami  of  the  ischia  and 
pubes :  the  urine,  therefore,  will  pass  along  those  situations 
where  it  meets  with  the  least  amount  of  resistance,  and  it  will 
become  extravasated  freely  into  the  scrotum,  distending  it 
exceedingly;  it  may  then  extend  upwards  to  the  anterior  wall 
of  the  abdomen,  conducted  by  the  spermatic  cord;  and  de- 
scend over  Poupart's  ligament  into  the  superficial  fascia  of 
the  upper  portion  of  the  thigh. 


298 


ANO-PERINEAL   REGION. 


In  this  stage  of  the  dissection  the  student  will  find  the 
superficial  sphincter  lying  between  the  layers  of  the  super- 
ficial fascia;  and  whilst  removing  the  integument  from  off 
this  muscle  he  will  observe  what  an  exceedingly  small  amount 
of  superficial  fascia  lies  between  it  and  the  skin :  it  is  closely 
connected  with  the  integuments,  and  is  of  an  elliptical  form; 


Fig.  i't 


■View  of  the  Perineum,  exhihiting  the  distribution  of  the  Internal  Pudic 
A  rtenj. 


1,  The  Internal  Pudic  issuing  fiom  tlie  Pelvis  at  the  lower  part  of  the  great  Sacro-Sciatic  Foramen. 
2,  The  same  vessel  after  it  has  returntd  into  the  Pelvis  through  the  small  Sacto-Sciatic  Foramen.  3, 
Inferior  Hsemorrhoidal  Artery.  4,  5,  Superficial  Perineal  branches  to  the  Perineum.  6,  Transverse 
Perineal.  7,  Perineal  branch  to  the  Scrotum  and  skin  of  the  Penis.  8,  Bulbourethral  Artery.  9, 
Cavernous  Artery.  10,  Dorsal  Artery  of  the  Penis,  o,  Tuberosity  of  the  Lschium.  fc.  Greater  Sacro- 
Sciatic  Ligament,  c.  Sphincter  of  the  Anus,  d.  Perineal  Fascia,  which  is  removed  on  the  opposite 
«ide  so  as  to  expose  the  Anal  Elevator  Muscle,  e,  lschio-Caveruou8  Muscle.  /,  Bulbo-urethral  Muscle. 

its  posterior  attachmeyit,  or  origin,  is  to  the  ano-coccygeal 
ligament,  which  springs  from  the  tip  of  the  coccyx  pos- 
teriorly, and  runs  forwards  to  be  connected  with  the  back  of 
the  rectum ;  this  ligament  is  merely  a  raphe  formed  by  the 
union  of  the  posterior  portions  of  the  levatores  ani  on  the 
middle  line :  the  anterior  attachment  of  the  sphincter  is  to  the 
central  point  of  the  perineum,  which  is  situated  immediately 


ANO-PERINEAL   REGION.  299 

behind  the  bulb :  into  this  point  we  have  inserted  the  follow- 
ing muscles  : — superficial  sphincter,  acceleratores  urinae,  trans- 
versi  perinei,  and  Wilson's  muscles.  We  may  now  remove 
the  entire  of  the  superficial  fascia  from  both  the  proper  peri- 
neal and  the  anal  spaces;  and  we  will  thus  expose,  in  the 
former  space,  the  middle  perineal  fascia,  and,  in  the  latter, 
the  two  ischio-rectal  fossae  or  spaces. 

The  middle  perineal  fascia  will  be  seen  when  the  super- 
ficial fascia  has  been  carefully  removed;  it  covers  the  under 
surface  of  the  muscles  of  the  perineum,  and  sends  ia  septa 
between  them  from  its  deep-seated  surface;  it  is  to  these 
muscles  what  the  fascia  lata  is  to  the  muscles  of  the  thigh, 
and  it  is  by  some  considered  to  be  an  extension  of  this  fascia 
across  the  perineum.  Anteriorly  it  is  lost  in  a  thin,  loose, 
delicate  expansion  along  the  urethra  and  crura  penis;  late- 
rally it  is  attached  to  the  rami  of  the  ischia  and  pubes;  and 
posteriorly,  in  the  middle  line,  it  is  connected  with  the  cen- 
tral point  of  the  perineum,  whilst  external  to  this  point  it  is 
reflected  behind  the  transverse  perineal  muscles,  and  is  lost 
by  becoming  continuous  with  the  two  layers  of  fascia,  which 
form  the  "  anterior  cul  de  sac"  of  the  ischw-i-ectal  space  or 
fossa.  This  latter  space  may  now  be  examined  :  it  is  bounded 
internallj/  by  the  rectum,  and  the  levator  ani  muscle  covered 
on  its  outer  surface  by  the  ischio-rectal  layer  of  the  obturator 
fascia;  extcrnalhj  by  the  proper  obturator  fascia  covering  the 
obturator  internus  muscle,  and  continuous  inferiorly  with  the 
falciform  process  of  the  great  sacro-sciatic  ligament,  and  by 
the  tuberosity  of  the  ischium  :  anteriorly  by  the  transverse 
muscles  of  the  perineum,  and  by  the  union  of  the  ischio-rectal 
with  the  proper  obturator  fascia,  forming  an  anterior  "  cul  de 
sac,"  or  fossa,  with  which,  as  we  have  already  stated,  we  find 
continuous  the  posterior  part  of  the  middle  perineal  fascia : 
posteriorlt/  by  another  "  cul  de  sac,"  formed  by  the  ischio- 
rectal and  proper  obturator  fascia,  becoming  continuous  above 
the  great  sacro-sciatic  ligament  and  inferior  border  of  the 


300  ANO-PERINEAL   REGION. 

glutaeus  maximus  muscle.  The  superior  boundary  of  this 
space  is  limited  by  the  splitting  of  the  obturator  fascia  into 
the  proper  obturator  and  ischio-rectal  fascia;  the  space  itself 
is  filled  with  a  large  quantity  of  adipose  and  coarse  areolar 
tissue,  which  inferior ly  is  incorporated  with  the  superficial 
fascia  of  the  ano-perineal  region. 

The  middle  perineal  fascia  should  now  be  removed ;  when 
the  muscles  of  the  proper  perineal  spaces  will  be  exposed ; 
these  are  three  at  each  side,  viz. :  in  the  middle  line  the 
accelerator  iirinae,  externally  the  erector  penis,  and  poste- 
riorly the  transversus  perinei. 

The  Accelerator  Urvnse  or  compressor  uretJirse  muscle  will 
be  seen  in  this  stage  of  the  dissection  taking  its  origin  from 
the  anterior  layer  of  the  triangular  ligament  near  its  base, 
and  more  anteriorly  from  the  side  of  the  corpus  cavernosum 
penis ;  the  third  origin  of  this  muscle  will  be  seen  in  a  future 
state  of  the  dissection  arising  by  a  tendinous  expansion  com- 
mon to  the  two  muscles,  and  situated  between  the  corpus 
spongiosum  urethrge  and  the  corpus  cavernosum  penis :  the 
fibres  which  arise  from  the  corpus  cavernosum  pass  obliquely 
downwards  and  backwards,  and  meet  in  the  middle  line  under- 
neath the  urethra;  as  they  approach  each  other  they  present 
on  the  inferior  surface  of  the  urethra  the  form  of  the  letter 
V,  the  apex  being  directed  posteriorly.  The  fibres  which 
arise  by  a  common  tendon  above  the  corpus  spongiosum  pass 
directly  downwards,  and  by  their  union  surround  the  urethra 
completely  like  a  sphincter  muscle  :  the  fibres  from  the  trian- 
gular ligament  pass  downwards  and  forwards.  All  these  dif- 
ferent fibres  are  inserted  along  the  middle  line  in  a  raph^, 
which  runs  along  the  inferior  surface  of  the  urethra  and  ter- 
minates posteriorly  in  the  central  point  of  the  perineum.  The 
Erector  Penis  arises  from  the  inner  surface  of  the  tuberosity 
of  the  ischium,  internal  to  the  origin  of  the  crus  penis ;  it 
passes  somewhat  spirally  with  regard  to  this  latter  structure, 
in  the  fibrous  covering  of  which  its  tendinous  insertion  is 


ANO-PERINEAL  REGION.  301 

ultimately  lost.  The  Transversus  Perinei  muscle  arises  from 
the  inner  surface  of  the  tuberosity  of  the  ischium  close  to  the 
origin  of  the  latter  muscle :  its  fibres  pass  forwards  and  in- 
wards towards  its  fellow  of  the  opposite  side  :  these  two  mus- 
cles meet  at,  and  are  inserted  into,  the  central  point  of  the 
perineum.     They  present,  not  a  straight  line  as  their  name 

Fig.  48. — Represents  the  Surgical  Anatomy  of  the  Ano-Perineal  region  in  the  Male., 
after  the  Integument,  Superficial  Fascia,  and  Superficial  Vessels  have  been  removed. 

% 


A,  Tiie  Corpus  Spongiosum  UrethriP.  B.  The  Ac.colerntores  Urinne  Muscles,  with  their  central 
Raph^.  C.  The  Central  Point  of  ilie  Perineum.  D.  D.  The  Right  and  Left  Erector  Penis  Muscles. 
K,  E,  The  Transverse  Muscles  of  the  Perineum.  F,  The  Anus.  G,  G,  The  Tuberosities  of  the  Ischia. 
H,  The  Coccyx.  T,  I,  The  Great  Gluta;i  Muscles.  K,  K,  The  Levatores  Ani  Muscles.  L,  The  Left 
Artery  of  the  Bulb,  seen  through  an  opening  made  in  the  anterior  layer  of  the  Triangular  Liga- 
ment. 

implies,  but  a  curve,  the  concavity  of  which  looks  backwards 
towards  the  anus,  the  convexity  in  the  opposite  direction. 
These  two  muscles  constitute  a  natural  line  of  separation  be- 
tween the  anal  and  perineal  portions  of  this  region.  In  the 
triangular  space  formed  by  the  three  muscles  at  each  side  of 
the  urethra,  we  find  the  long  perineal  artery  nerve  and  vein, 
and  at  the  base  of  the  triangle  we  find  the  transverse  artery 
of  the  perineum.  These  two  arteries  are  situated,  shortly 
after  their  origins,  on  the  cutaneous  surface  of  the  transversus 
perinei  muscle. 

After   having   carefully  removed  these  muscles,  together 

26 


302  ANO-PERINEAL   REGION. 

with  the  perineal  arteries  veins  and  nerves  at  both  sides,  the 
triangular  ligament  of  the  wethra  or  deej:)  perineal  fascia 
will  be  exposed.  It  occupies  the  deepest  portion  of  the 
proper  perineal  space :  its  a/pcx  passes  in  front  of  the  sub- 
pubic ligament  to  which  it  is  attached,  and  is  ultimately  lost 
in  affording  a  covering  to  the  upper  surface  of  the  corpus 
cavernosum  penis :  its  sides  are  attached  to  the  rami  of  the 
ischia  and  pubes,  where  they  become  continuous  with  the 
obturator  fascia;  and  its  base  presents  the  appearance  of  a 
double  arch,  though  not  well  defined,  somewhat  resembling 
the  velum  pendulum  palati :  the  middle  portion  of  the  base 
is  connected  with  the  central  point  of  the  perineum,  and  the 
arched  portion  at  each  side  is  lost  by  becoming  continuous 
with  the  anterior  "  cul  de  sac"  of  the  ischio-rectal  fossa  under 
cover  of  the  transversus  perinei  muscle.  The  triangular 
ligament  is  divisible  into  two  layers,  the  anterior  or  super- 
ficial, and  the  posterior  or  deep ;  and  situated  between  the 
layers  we  find  the  following  parts : — externally,  close  to  the 
rami  of  the  ischia  and  pubes,  the  pudic  artery  of  each  side; 
near  the  base,  and  more  internally,  the  two  arteries  of  the 
bulb,  with  their  small  branches  to  the  bulb  of  the  urethra 
and  to  Cowper's  glands :  still  nearer  to  the  middle  line  we 
find  the  small  glands  of  Cowper,  with  their  ducts ;  a  quan- 
tity of  exceedingly  fine  areolar  tissue  is  also  situated  here, 
and  a  small  part  of  the  membranous  portion  of  the  urethra 
near  the  bulb  corresponds  to  the  interval  between  the  layers. 
Through  an  opening  in  this  ligament  is  transmitted  the 
urethra:  the  part  of  this  canal  which  pierces  the  ligament 
corresponds  to  the  junction  of  the  membranous  portion  with 
the  spongy  :  consequently,  the  spongy  portion,  which  includes 
the  bulb,  is  in  front  of  the  triangular  ligament,  and  the  prin- 
cipal portion  of  the  membranous  and  the  entire  of  the  pros- 
tatic portions  are  behind  it.  The  opening  for  transmitting 
the  urethra  is,  in  the  adult,  about  an  inch  below  the  sym- 
physis  pubis,  and   two  inches   from  the   tuberosity  of  the 


ANO-PERINEAL   REGION.  303 

ischium,  and  about  half  an  inch  above  the  centre  of  the  base 
of  the  ligament :  this  orifice  does  not  present  a  distinct  margin, 
as  there  is  a  production  sent  off  from  its  anterior  layer  for- 
wards over  the  spongy  portion,  and  another  backwards  (fun- 
nel-shaped) from  its  posterior  layer,  which  invests  the  mem- 
branous and  prostatic  portions  of  the  urethra.  It  is  this  latter 
production  that  is  usually  termed  the  posterior  layer  of  the 
triangular  ligament:  it  unites  with  the  vesical  fascia  and 
with  the  recto-vesical  fascia,  as  it  surrounds  the  prostate  gland. 
An  American  writer  states  that  the  part  of  it  on  the  inferior 
surface  of  the  prostate  gland  is  reflected  on  the  front  of  the 
rectum,  so  as  to  form  a  "cul  de  sac"  opposed  to  that  of  the 
peritoneum;  and  the  division  of  this  "cul  de  sac"  in  litho- 
tomy he  conceives  to  be  attended  with  considerable  risk  of 
abscesses  and  peritonitis. 

The  student  is  now  recommended  to  attend  to  the  anatomy 
of  thefdscise  of  the  pelvis,  with  which  that  of  the  perineum 
is  intimately  connected.  When  the  peritoneum  has  been  re- 
moved from  the  iliac  fossa  of  either  side,  the  fascia  iliaca 
will  be  exposed )  there  is,  however,  between  the  peritoneum 
and  the  iliac  fascia,  a  layer  of  adipose  and  loose  areolar  tissue 
intermixed,  which  extends  in  every  direction,  as  well  into  the 
pelvis  as  on  the  back  part  of  the  structures  which  form  the 
anterior  wall  of  the  abdomen.  If  we  examine  this  sub-peri- 
toneal layer  of  fascia,  we  will  find  that  as  we  trace  it  inter- 
nally towards  the  true  pelvis,  it  becomes  more  condensed  in 
its  structure,  and,  assuming  the  appearance  of  a  distinct  fascia, 
it  becomes  connected  with  the  fascia  iliaca  along  the  external 
side  of  the  external  iliac  artery ;  it  then  passes  around  this 
artery  and  its  accompanying  vein ;  and  internally  to  the  latter 
vessel  it  is  attached  to  the  pelvic  fascia.  It  is  not  always  of 
equal  strength,  but  sometimes  we  are  able  to  trace  distinct 
fibrous  bands  in  this  structure,  passing  across  the  artery  and 
the  vein.  By  means  of  this  fascia  the  vessels  are  connected 
together  in  a  proper  sheath j  and  are  more  or  less  securely  fixed 


304 


ANO-PERINEAL  REGION. 


upon  the  iliac  fascia  which  passes  behind  them.  This  fascia 
is  continuous,  inferiorly  behind  Poupart's  ligament,  with  the 
fascia  propria  of  Sir  A.  Cooper,  and  has  sometimes  been 
described  as  a  prolongation  of  this  latter  structure  upwards 
over  the  vessels  :  below  Poupart's  ligament  it  still  continues 
its  course  along  the  femoral  vessels,  forming  their  sheath. 
There  is  no  doubt  that  it  was  this  fascia  which  presented  an 
obstruction  to  the  passing  of  the  ligature  in  Mr.  Abernethy's 

Pig.  49. — Represents  the  Surgical  Anatomy  of  the  Male  Perineum  after  the  Integument, 
Superficial  Fascia,  portion  of  the  Acceleratores  Urinse  Muscles,  Superficial  Fessels, 
<&c.  have  been  removed. 


A,  The  Corpus  Spongiosum  Urcthrae.  B,  B,  The  anterior  forked  termination  of  the  Acceleratores 
Urinae  Muscles.  C,  Cowper's  Glands  and  their  Arterial  Twigs  from  the  .\rtery  of  the  Bulb  of  each 
side,  between  the  layers  of  the  Triangular  Ligament;  a  portion  of  the  anterior  layer  has  been  re- 
moved. D,  D,  The  Right  and  Left  Erector  Penis  Muscle.  R,  E,  The  Triangular  Ligament  or  Deep 
Perineal  Fascia.  F,  The  Anus.  G,  G,  The  Ischiatic  Tuberosities.  H,  The  Coccyx.  K,  K,  The  Le- 
vatores  Aui  Muscles.  L,  L,  Portion  of  the  Superficial  Fascia,  and  its  connection  to  the  Rami  of  Is- 
chium and  Pubis.  M,  The  Bulb  of  the  Urethra.  N.  N,  The  Great  Glutaii  Muscles.  O,  O,  Portioa 
of  the  Great  Sciatic  Ligament.    P,  The  SuperQcial  Sphincter  Muscle. 

second  operation  on  the  external  iliac  artery.  In  describing 
this  operation,  he  says,  "  The  pulsations  of  the  artery  made 
it  clearly  distinguishable  from  the  contiguous  parts,  but  I  could 
not  get  my  finger  round  it  with  the  facility  which  I  expected. 
This  was  the  only  circumstance  which  caused  any  delay  in  the 
performance  of  the  operation.  After  ineffectual  trials  to  pass 
my  finger  beneath  the  artery,  I  was  obliged  to  make  a  slight 


ANO-PERINEAL  REGION.  305 

incision  on  either  side  of  it,  in  the  same  manner  as  is  neces- 
sary when  it  is  taken  up  in  the  thigh,  where  the  fascia  which 
binds  it  down  in  its  situation  is  strong/^* 

The  student  may  now  follow  the  course  of  the/ascia  iliaca. 
This  fascia  is  attached  to  the  crest  of  the  ilium,  covers  the 
psoas  and  iliacus  internus  muscles  and  anterior  crural  nerve ; 
and  passes  underneath  or  behind  the  external  iliac  vessels,  in 
order  to  descend  into  the  true  pelvis.  At  its  connection  with 
the  brim  of  the  pelvis,  it  receives  the  name  of  pelvic  fascia. 
Having  descended  as  far  as  the  upper  edge  of  the  levator 
ani,  it  divides  into  two  layers,  between  which  this  muscle  is 
placed;  the  internal  layer  or  vesical  descends  towards  the 
bottom  of  the  pelvis,  and  then  ascends  on  the  side  of  the 
bladder  and  its  neck,  where  it  unites  with  the  posterior  layer 
of  the  triangular  ligament.  This  vesical  layer  is  confined  to 
the  anterior  and  lateral  part  of  the  neck  of  the  bladder,  and 
goes  no  farther  back,  along  the  side  of  this  viscus,  than  the 
spine  of  the  ischium :  hence  the  bladder,  when  dilating,  per- 
forms a  rotation  which  throws  its  upper  extremity  forwards^ 
on  account  of  its  being  tied  down  anteriorly,  while  the  poste- 
rior part  is  at  liberty  to  dilate.  From  the  inferior  surface  of 
the  vesical  fascia  we  find  two  layers  passing  ofi*, — one  between 
the  rectum  posteriorly,  and  the  inferior  fundus  of  the  bladder 
and  under  surface  of  the  prostate  gland,  called  the  recto- 
vesical or  Tyrrell's  fascia;  the  other  passing  along  the  sides 
and  on  the  under  surface  of  the  rectum,  called  the  rectal 
fascia.  The  external  layer  of  the  pelvic  fascia,  or  the  ohtu- 
rator  fascia y  descends  between  the  obturator  internus  muscle 
and  levator  ani,  and  divides  into  the  proper  obturator  fascia 
and  the  ischio-rectal  or  anal  fascia.  Now,  these  are  the  two 
fasciae  which  line  the  ischio-rectal  cavity, — viz.,  the  obturator 
on  the  outside,  and  the  ischio-rectal  on  the  inside :  the  former 
has  its  external  surface  applied  to  the  obturator  muscle  and 


*•  Abernethy's  Surgical  Works,  vol.  i.  p.  307. 
26* 


306      LATERAL  OPERATION  FOR  LITHOTOMY. 

pudic  artery,  and  its  inferior  edge  is  inserted  into  a  production 
of  the  great  sacro-sciatic  ligament;  while  the  latter,  pecu- 
liarly thin,  is  applied  to  the  outer  surface  of  the  levator  ani 
and  lower  part  of  the  rectum. 

The  arteries  of  the  ano-perineal  region  will  be  described 
when  speaking  of  the  branches  of  the  internal  pudio. 
•  The  Lateral  Operation  for  Lithotomy. — The  rectum  having 
been  previously  emptied  by  an  enema,  and  the  patient  desired 
to  retain  his  urine,  the  hair  of  the  perineum  should  be  shaved, 
and  the  presence  of  the  stone  again  ascertained.  A  grooved 
staff  is  then  to  be  introduced  into  the  bladder,  and  the  patient 
tied,  as  already  directed  when  speaking  of  the  dissection  of 
this  region,  and  laid  on  his  back,  on  a  table  of  convenient 
height.  The  scrotum  being  raised  by  an  assistant,  the  ope- 
rator, sitting  on  a  low  chair,  or  kneeling  on  one  knee  before 
the  patient,  holds  the  staff  vertically  in  his  left  hand,  keeping 
it  firmly  drawn  upwards,  and  at  the  same  time  making  it  sufi&- 
ciently  prominent  in  the  perineum.  Some  prefer  committing 
the  staff  to  the  care  of  an  assistant  during  the  operation.  The 
first  incision  should  be  commenced  about  half  an  inch  below 
the  symphysis  pubis,  or  at  a  point  corresponding  to  about  an 
inch  in  front  of  the  anus,  and  carried  downwards  and  out- 
wards on  the  left  side  of  the  perineum,  until  it  has  fairly 
passed  the  interval  between  the  rectum  and  tuberosity  of  the 
ischium.  This  incision  will  divide  the  superficial  fascia  and 
probably  the  outer  portion  of  the  superficial  sphincter,  and 
form  a  wide,  gaping  wound.  The  second  incision  should  com- 
mence about  half  an  inch  lower  down  than  the  commence- 
ment of  the  first,  and,  being  carried  in  the  same  direction,  will 
almost  invariably  divide  the  long  perineal  artery  and  nerve, 
and  certainly  the  transverse  artery  of  the  perineum,  and  will 
pass  between  the  accelerator  urinse  and  erector  penis  muscles. 
It  should  also  be  carried  sufficiently  far  back  to  cut  across  the 
transversus  perinei  muscle.  The  staff  is  now  to  be  lateralized, 
so  as  to  turn  its  convexity  a  little  to  the  operator's  right  side. 


LATERAL  OPERATION  FOR  LITHOTOMY.      307 

The  point  of  the  knife  should  now  be  passed  through  the  base 
of  the  triangular  ligament,  and  then  carried  behind  the  bulb 
into  the  membranous  portion  of  the  urethra,  in  which  the 
grooved  stafif  will  be  felt.  By  passing  the  knife  into  this  part 
of  the  urethra  sufficiently  behind  the  bulb,  the  artery  of  the 
bulb  will  be  avoided.  As  soon  as  the  point  of  the  knife  has 
been  made  to  enter  the  groove  in  the  staff,  it  should  be  moved 
in  it  from  side  to  side,  in  order  to  be  certain  that  it  is  fairly 
in  contact  with  this  instrument.  In  performing  this  incision 
into  the  membranous  portion  of  the  urethra,  the  edge  of  the 
knife  should  neither  be  turned  too  much  outwards,  for  fear  of 
wounding  the  pudic  artery,  nor  too  much  inwards,  lest  the 
rectum  be  wounded,  but  in  an  intermediate  direction.  The 
point  of  the  knife  must  now  be  passed  onwards  steadily  in 
the  long  axis  of  the  prostate  gland,  giving  it,  at  the  same 
time,  by  depressing  its  handle,  the  direction  upwards  as  if 
towards  the  anterior  wall  of  the  abdomen;  and  according  as 
the  knife  is  thus  made  to  move  along  the  groove,  the  handle 
of  the  staff  should  be  simultaneously  depressed.  In  this 
manner  the  membranous  and  anterior  part  of  the  prostatic 
portion  of  the  urethra  will  be  divided ;  and  as  the  urethra,  in 
passing  through  the  prostate  gland,  is  nearer  to  its  upper  than 
to  its  lower  surface,  one-third  of  the  gland  will  be  left  above 
the  incision,  and  two-thirds  below.  The  knife  being  with- 
drawn, the  first  finger  of  the  left  hand  is  to  be  introduced  into 
the  incision,  and  the  nail  of  it  into  the  groove  in  the  staff. 
The  surgeon  now  lays  aside  the  first  knife,  and  next  employs 
a  long,  narrow,  probe-pointed  knife,  which  he  inserts  into  the 
groove  in  the  staff,  directed  by  the  fore-finger  of  the  left  hand. 
With  this  instrument  carefully  pushed  in  the  direction  already 
indicated,  so  much  of  the  prostate  gland  will  be  divided  as 
may  be  considered  necessary.  This  knife  having  been  with- 
drawn, the  surgeon  should  insert  the  fore-finger  of  the  left 
hand  into  the  wound  in  the  prostate,  and  so  pass  it  along  the 
staff  into  the  neck  of  the  bladder.     When  the  surgeon  feels 


308  LATERAL   OPERATION    FOR   LITHOTOMY. 

that  the  passage  is  now  clear  into  the  bladder,  he  should  still 
keep  his  finger  in  the  same  position,  its  dorsal  surface  being 
directed  upwards;  he  will  then  take  the  blunt  gorget  in  his 
right  hand,  and,  resting  its  concavity  on  the  dorsum  of  the 
index  finger  of  his  left,  he  will  steadily  pass  it  along  into  the 
bladder.  The  staff  should  now  be  withdrawn;  the  gorget 
should  be  then  turned  so  as  to  direct  its  concavity  upwards, 

Fig.  50. — Represents  the  Surgical  Anatomy  of  the  deep  poHions  of  the  Male  Perineum. 
The  Rectum  has  been  divided  and  turned  hack.  Left  Crus  Penis  divided  and  a  por- 
tion removed 


A,  Corpus  Spongiosum  tJrethrae.  B,  The  Bulb.  C,  0,The  two  lateral  Lobes  of  the  Prostate.  D, 
The  Right  f:rector  Peuis  Muscli'.  E,  The  left  Crus  Penis  divided  so  as  to  show  the  Artery  of  the 
Corpus  Cavernosum.  F,  The  Rectum  turned  down.  G,  G,  The  Tuberosities  of  the  Ischia.  I,  I, 
The  Great  Glutiei  Muscles.  K,  K,  The  Levatores  Ani  Muscles  divided  and  partly-  removed.  M,  The 
membranous  portion  of  Urethra.  N,  N,  The  Vesicula;  Seniinales.  O,  O,  The  Great  Sciatic  Liga- 
ment. P,  The  base  of  the  Bladder.  Q,  Q,  The  two  Vasa  Deferentia  becoming  tortuous  before  their 
termination. 

whilst  the  handle  of  the  instrument  should  be  depressed  at 
the  same  moment :  in  this  movement  the  stone  may  possibly 
roll  along  the  gorget  into  the  hand  of  the  operator;  if  not, 
however,  the  forceps  should  be  introduced  on  the  concavity 
of  the  gorget,  one  of  its  blades  being  directed  upwards,  and 
the  other,  of  course,  downwards.  When  this  instrument  is 
fairly  within  the  bladder,  the  gorget  may  be  withdrawn,  and 
the  forceps  turned  so  that  the  blades  will  look,  one  inwards 
and  the  other  outwards.  At  first  it  is  only  to  be  used  as  a 
probe  to  feel  for  the  stone ;  when  this  is  ascertained,  it  is  to 


INTERNAL  PUDIC  ARTERY. 


309 


be  taken  hold  of  by  its  short  axis  and  withdrawn.  If  it  be 
very  large,  it  may  be  necessary  to  break  it  with  Le  Cat's  for- 
ceps, and  in  this  case  great  care  will  be  necessary  to  wash  out, 
subsequently,  every  remaining  fragment.  If,  after  the  opera- 
tion, we  find  the  urine  does  not  come  through  the  wound,  but 
through  the  urethra,  and  stained  with  blood,  we  know  that 
hemorrhage  has  occurred :  we  should,  therefore,  at  once  re- 

Fig.  bl.— Represents  the  Normal  Relations  of  the  parts  concerned  in  Lithotomy  per- 
formed in  the  Perineal  Region.    (After  Maclise.) 


A,  A,  Median  line  intersecting  B,  B,  a  transverse  line  dividing  the  Perineum  into  the  Anterior 
and  Posterior  Regions.  C,  The  incision  through  the  integument  crossing  at  an  acute  angle  the  in- 
cision D,  which  divides  the  Prostate. 

move  the  clots  which  block  up  the  wound,  and  fill  it  with  a 
sponge,  or  with  charpie,  surrounded  by  a  small  bag,  and  se- 
cured to  a  female  catheter  which  has  been  previously  passed 
through  them.  The  catheter  should  be  made  to  enter  fairly 
within  the  bladder,  in  order  to  allow  the  free  escape  of  the 
urine. 


The  Internal  Pudic  Artery. — The  description  of  this 
vessel  has  been  purposely  deferred  till  the  present  stage  of 


310  INTERNAL   PUDIC    ARTERY. 

the  dissection  of  the  pelvis.  This  artery  is  larger  than  the 
obturator,  but  smaller  than  the  sciatic,  with  which  it  usually 
arises  in  common.  It  may  be  divided  into  four  stages:  in 
the  first  it  lies  within  the  cavity  of  the  pelvis ;  in  the  second 
it  is  situated  outside  this  cavity;  in  the  third  it  is  again 
within  its  osseous  walls;  and  in  the  fourth  stage  it  is  lodged 


Fig.  52. — Represents   the  course  of  the  Internal  Pudlc  Artery  to  its  terminati 
The  Viscera  and  Fasciic  have  been  removed. 


A,  Aorta.  B,  Lefl  Comnmn  Iliac  Artery  divided.  C,  Right  Common  Iliac.  D.  Kxternal  Iliac. 
E,  Internal  Iliac,  a,  Situatioa  of  the  origin  of  the  Episastric  Artery,  b,  Circumflexa  Ilii  Artery, 
d,  Umbilical  Artery  divided,  e,  Anterior  part  of  the  Internal  Iliac,  f,  Posterior  part,  g,  Obturator 
Artery,  h,  A  small  artery  sondin?  twigs  into  the  first  Sacral  Foramen.  I,  Lateral  Sacral  Artery, 
k,  Glulieal  Artery  passing  out  of  the  Pelvis  above  and  in  front  of  the  first  Sacral  Nerve.  1,  The  Sciatic 
Artery,  m,  m,  Internal  Pudio  Artery,  n,  A  Hieniorrhoidal  branch  from  the  Internal  Pudic  in  its 
first  stage,  o,  Kxternal  Hemorrhoidal  Arteries.  P,  Lone,  or  Superficial  Perineal  Artery,  giving  off 
in  this  instance  s,  the  transverse  Perineal  branch,  r,  Scrotal  branches  of  the  Superficial  Perineal 
Artery,  t,  t.  t.  Dorsal  Artery  of  the  Penis.  1,  Symphysis  Pubis.  2,  Crest  of  Ilium.  3.  3,  Bodies 
of  the  fourth  and  fifth  Lumbar  Vertebra?.  4,  4,  Sacriim.  5.  Coccyx.  6,  Lesser  Sciatic  Licament, 
with  Coccygeus  Muscle.  7,  Great  Sciatic  Ligament.  8.  A  portion  "of  the  lower  end  of  the  Rectum. 
9,  Right  half  of  the  lilxternal  or  superficial  Sphincter.  10,  Spine  of  the  Ischium.  11,  Obturator  In- 
ternus  Muscle.  12,  Septum  Scroti.  13,  Membranous  part  of  the  Urethra  dissected  and  cut.  14.  Bulb- 
ous portion  of  Corpus  Spongiosum.  15,  Section  of  left  Corpus  Cavernosum.  16,  Suspensory  Liga- 
ment of  the  Penis. 

between  the  two  layers  of  the  triangular  ligament  of  the 
urethra.  In  the  first  stage  it  descends  in  front  of  the  sacral 
plexus  of  nerves  and  pyriformis  muscle,  between  the  rectum 
and  outer  wall  of  the  pelvis.  Usually  it  lies  at  first  some- 
what external  to  the  sciatic  artery,  but  at  the  lower  por- 
tion of  the  first  stage  it  lies  anterior  and  internal  to  it,  ani 


INTERNAL   PUDIC   ARTERY.  311 

escapes  from  this  cavity  through  the  inferior  part  of  the  great 
sciatic  notch,  accompanied  by  its  own  nerve,  the  sciatic  artery, 
and  the  sciatic  nerve.  At  its  exit  from  the  pelvis  it  passes 
between  the  lower  edge  of  the  pyriformis  muscle  and  the 
lesser  sacro-sciatic  ligament.  After  the  pudic  artery  has 
escaped  from  the  pelvis,  it  enters  its  second  stage,  and  in  this 
situation  lies  behind  the  spine  of  the  ischium,  near  the 
attachment  of  the  lesser  sacro-sciatic  ligament  to  its  point. 
Here,  as  we  dissect  the  artery  from  behind,  we  will  find  it 
covered  by  the  glutaeus  maximus  muscle,  by  a  small  portion 
of  the  great  sciatic  ligament,  and  by  the  ramus  coccygeus  of 
the  sciatic  artery.  The  pudic  artery  next  re-enters  the  bony 
parietes  of  the  pelvis  by  the  lesser  sciatic  notch,  and  thus 
gets  into  its  third  stage.  As  it  is  passing  through  this  notch, 
we  may  observe  the  obturator  internus  muscle  also  escaping 
through  it  from  the  pelvis,  the  muscle  lying  closer  to  the 
bone.  The  artery  in  its  third  stage  ascends  towards  the  base 
of  the  triangular  ligament,  lying  between  the  obturator  muscle 
and  fascia,  in  a  kind  of  prismatic  canal,  which  is  bounded 
internally  by  the  obturator  fascia  and  its  union  with  the  semi- 
lunar production  of  the  great  sacro-sciatic  ligament,  which 
latter  extends  as  far  forwards  as  the  crus  penis )  externaUy  by 
the  ischium  and  obturator  internus,  and  inferiorlt/j  where  we 
observe  the  narrow  portion  of  the  canal,  it  is  bounded  by  the 
attachment  of  the  great  sciatic  ligament  to  the  ischium.  Pro- 
fessor Alcock  maintains,  that  corresponding  to  this  situa- 
tion the  artery  does  not  lie  between  the  fascia  and  the 
muscle,  but  that  it  is  contained  "in  a  canal  in  the  obturator 
fascia."* 

The  pudic  artery,  finally,  pierces  the  back  part  of  the  tri- 
angular ligament,  near  the  external  attachment  of  its  base, 
and  enters  its  fourth  stage.     In  this  stage  the  artery  of  each 

«■  Todd's  Cyclopaedifi,  p.  835. 


312 


INTERNAL   PUDIC   ARTERY. 


side  is  situated  between  the  two  layers  of  the  ligament  corre- 
sponding to  the  attachment  of  its  sides  to  the  rami  of  the 
ischia  and  pubes;  and  close  to  the  sub-pubic  ligament  it 
pierces  the  anterior  layer  of  the  triangular  ligament  at  its 
apex,  and  terminates  in  the  dorsal  artery  of  the  penis. 
Throughout  these  several  stages  the  pudic  nerve  accompanies 
the  artery. 

Fig.  53. — Represents  the  Surgical  Anatomy  of  the  Ano-perineal  Region  in  the  Male, 
when  the  integuments  and  superficial  fascia  have  been  removed. 


A,  Portion  of  the  Superficial  Fascia.  B.  Tlie  central  point  of  the  Perineum.  C,  The  Coccyx. 
I>,  D,  The  Ischiatic  Tuberosities.  K,  The  Acccleratores  Urinas  Muscles  meeting  in  the  central  Raph6. 
F,  F,  The  Ercctores  Penis  .Muscles  of  each  side.  O,  The  Transverse  Muscle  of  the  Perineum  of  the 
right  side.    H,  The  Anus.    I,  I,  The  Great  Gluta;al  Muscles. 


Within  the  pelvis  the  pudic  artery  gives  off  branches  to  the 
rectum,  bladder,  and  vesiculse  seminales  in  the  male,  and  to 
the  upper  part  of  the  vagina  in  the  female  : — to  the  muscles 
and  sacral  plexus  of  nerves. 

As  the  artery  turns  round  the  spine  of  the  ischium,  it  sup- 
plies the  gluta3us  maximus  and  rotator  muscles  in  this  situa- 
tion. Its  principal  branches  arc  given  off  in  its  third  and 
fourth  stages.     They  are  the  following  : — 


BRANCHES    OP   INTERNAL   PUDIC.  313 

External  or  Inferior  Ha3-         Artery  of  the  Bulb. 

morrlioidal.  Artery  of  Corpus  Caver- 
Long  or   Superficial  Peri-             nosum. 

neal.  Dorsal  Artery  of  the  Pe- 

Transverse  Perineal.  nis. 

The  External  Hsemorrhoidal.  These  arteries,  generally 
two  in  number,  come  off  from  the  pudic  artery  in  its  third 
stage,  and  pierce  the  obturator  fascia  to  reach  the  inferior 
part  of  the  rectum.  They  supply  the  mass  of  adipose  and 
areolar  tissue  in  the  ischio-rectal  excavation,  together  with 
the  parts  belonging  to  the  lower  portion  of  the  rectum  and 
the  skin  of  this  region,  and  communicate  with  the  middle 
and  superior  hsemorrhoidal  arteries. 

The  Long  Perineal  Artery  arises  from  the  pudic  in  its 
third  stage,  pierces  the  obturator  fascia,  then  curves  under, 
that  is,  posterior  and  superficial  to  the  transversus  perinei 
muscle,  and  advances  in  company  with  the  inferior  perineal 
nerve  and  vein  in  the  triangular  space  between  the  erector 
penis,  accelerator  urinse,  and  transversus  perinei  muscles; 
being  nearer  to  the  ischium  than  to  the  raphe  or  middle  line 
of  the  perineum.  In  this  course  it  supplies  the  two  last- 
mentioned  muscles  and  the  sphincter  ani  and  integuments, 
after  which  it  penetrates  the  septum  scroti  and  forms  a  net- 
work of  vessels,  both  in  the  septum  and  in  the  subcutaneous 
areolar  tissue  of  the  rest  of  the  scrotum.  It  anastomoses  with 
the  arteries  of  the  spermatic  cord  and  with  the  external  pudic 
arteries.  This  artery  may  possibly  escape  in  the  lateral  opera- 
tion for  the  stone. 

In  the  female  this  branch  is  larger  in  proportion  to  the 
other  branches,  and  is  the  artery  of  the  labium. 

The  Transverse  Artery  of  the  Perineum  is  a  small  branch 
which  arises  from  the  pudic  at  the  termination  of  its  third 
stage ;  it  then  pierces  the  obturator  fascia  in  this  situation, 
and  the  base  of  the  triangular  ligament,  and  passes  inwards 

27 


314  BRANCHES   OF   INTERNAL   PUDIC. 

and  forwards  on  tlie  cutaneous  surface  of  the  transversus 
perinaei  muscle,  which  it  supplies;  it  then  passes  to  the  cen- 
tral point  of  the  perineum,  where  it  anastomoses  with  the 
artery  of  the  opposite  side.  This  artery  is  sometimes  a 
branch  of  the  long  perineal :  it  is  necessarily  divided  in  the 
lateral  operation  for  the  stone. 

The  Artery  of  the  Bulb.  This  artery  arises  from  the  pudic 
in  its  fourth  stage ;  it  then  passes  downwards,  forwards,  and 
inwards,  between  the  layers  of  the  triangular  ligament,  near 
its  posterior  lunated  margin,  and  terminates  by  dividing  into 
two  branches;  viz.:  a  small  one  to  Cowper's  gland,  and  a 
larger  to  the  bulb  of  the  urethra. 

On  account  of  the  fibrous  structure  through  which  this 
artery  passes,  it  cannot  retract  when  divided :  hence  the  great 
danger  from  hemorrhage  when  it  has  been  wounded  in  litho- 
tomy. In  order  to  avoid  this  accident,  the  operator  should 
endeavor  to  open  into  the  membranous  portion  of  the  urethra 
towards  its  lower  surface,  and  as  far  behind  the  bulb  as 
possible. 

The  Artery  of  the  Corpus  Cavernosum.  This  artery  arises 
from  the  pudic  immediately  after  it  has  passed  through  the 
anterior  layer  of  the  triangular  ligament :  it  then  pierces  the 
crus  penis,  and  advances  through  the  corpus  cavernosum, 
distributing  its  branches  on  either  side,  and  gradually  ap- 
proaching the  middle  line.  It  communicates  through  the 
septum  pectin  if orme  with  the  artery  of  the  opposite  side,  and 
ramifies  in  the  areolar  tissue  of  the  corpus  cavernosum. 

The  following  is  Midler's  opinion  as  to  the  distribution  of 
the  arteries  of  the  corpus  cavernosum  : — "  The  arteries  of  the 
corpus  cavernosum  have  two  sets  of  branches : — the  one  set 
are  the  ultimate  ramuscules,  which  terminate  in  the  minute 
radicles  of  the  veins,  and  are  destined  for  the  nutrition  of  the 
part;  the  other  set  come  off  from  the  side  of  the  arteries, 
and  consist  of  short,  slightly  curled  branches,  terminating 
abruptly  by  a  rounded,  apparently  closed  extremity,  turned 


MINUTE  ARTERIES  OF  CORPUS  CAVERNOSUM.    315 

back  somewhat  on  itself.  These  are  sometimes  single;  some- 
times several  arise  by  one  stem,  forming  a  tuft.  I  have 
named  them  arterise  helicivse.  They  project  into  the  venous 
cells,  and  are  found  principally  in  the  posterior  part  of  the 
corpora  cavernosa,  and  of  the  corpus  spongiosum  urethra). 
They  are  not  distinct  in  man.  Although  no  openings  can  be 
discovered  in  the  coats  of  these  free  arterial  excrescences,  yet 


Fig.  54. — Represents  the  Surgical  Anatomy  of  the  Male  Perineum:  the  Orus  Penis  of 
each  side  divided  and  partly  removed.  The  membranous  portion  of  Urethra  divided 
behind  the  Bulb  ;  and  the  latter  with  the  Corpus  Spongiosum  are  tm-ned  forwards. 
T/ie  urethral  opening  in  Triangular  Ligament  is  seen,  as  well  as  the  vessels  between 
its  layers.     The  anterior  layer  opened  and  some  of  it  cut  away. 


B,  The  Bulb.  C,  Cowpcr's  Glands  receiving  twigs  from  the  Artery  of  the  Bulb.  D.  D,  The  two 
Crura  Penis.  E,  K,  The  Triangular  Ligament  or  deep  Perineal  Fascia;  a  portion  of  its  anterior 
lai-er  removed.  V,  The  Anus.  G,  G,  The  Tuberosities  of  the  Ischia.  H,  The  Coccyx.  1,  I,  The 
Great  Gluta-i  Muscles.  K,  K.  The  Levatores  Ani  Muscles  partly  removed.  L,  The  Artery  of  the 
Bulb  divided.  M,  The  Urethral  opening  in  Triangular  Ligament.  N,  N,  The  Rectum.  O,  The 
Great  Sciatic  Ligament. 

there  is  no  doubt  but  that  it  is  through  them  that  the  blood, 
which  is  ordinarily  carried  into  the  texture  of  the  corpora 
cavernosa  by  the  minute  nutrient  branches  of  the  arteries,  is, 
in  the  act  of  erection,  poured  directly  into  the  venous  cells 
and  sinuses.  When  the  arteria  corporis  cavernosi  is  injected 
with  size  and  vermilion,  the  injected  matter  always  fills  the 
venous  cells ;  and  if  it  is  afterwards  washed  from  them,  the 
arteriae  helicinae  will  be  seen  injected.    The  means  by  which, 


316  BRANCHES    OF   INTERNAL   PUDIC. 

during  life,  they  are  enabled  to  force  blood  into  the  cells  must 
be  the  increased  attraction  exerted  between  their  coats  and 
the  blood  by  the  nervous  influence  transmitted  to  them  by 
the  spinal  cord,  in  consequence  of  which  attraction  an  in- 
creased quantity  of  blood  goes  to  them.  This  throws  new 
light,  at  the  same  time,  upon  the  mutual  action  of  the  blood 
and  smaller  vessels  in  other  parts,  and  upon  the  phenomenon 
of  active  turgescence,  or  turgor  vitalis.  The  blood  is  returned 
from  the  corpora  cavernosa  partly  by  small  veins,  running,  at 
the  sides  and  on  the  surface  of  these  bodies,  into  the  vena 
dorsalis,  partly  by  deeper  veins,  which  issue  from  the  corpora 
cavernosa  at  their  root,  and  enter  immediately  the  venous 
plexus,  situated  behind  the  symphysis  pubis.  The  fact,  then, 
that  the  vena  dorsalis  does  not  return  the  blood  from  the 
deep  veins,  shows  that  no  pressure  on  the  former  vein  alone 
can  cause  accumulation  of  blood  in  the  penis."* 

The  Dorsal  Artery  of  the  Penis  is  the  terminating  artery 
of  the  internal  pudic;  it  ascends  between  the  crus  penis  and 
symphysis  pubis,  then  advances  in  front  of  the  sub-pubic 
ligament,  and  through  the  substance  of  the  suspensory  liga- 
ment of  the  penis,  to  arrive  in  the  longitudinal  groove  on  the 
upper  surface  of  the  corpus  cavernosum.  As  it  advances  in  this 
groove,  it  supplies  the  integuments  and  fibrous  layer  of  the 
corpus  cavernosum.  Having  arrived  as  far  as  the  glans  penis, 
it  communicates  with  its  fellow  of  the  opposite  side,  both  above 
and  below,  so  as  to  form  a  vascular  ring,  from  which  vessels 
are  detached  to  the  glans  and  the  prepuce.  The  correspond- 
ing nerve  accompanies  the  artery  lying  on  its  outside ;  and 
the  dorsal  vein,  which  is  common  to  both  arteries,  is  found 
on  the  middle  line  between  them. 

In  the  female,  the  terminating  branches  of  the  pudic 
artery  are  distributed  in  an  analogous  manner ;  that  is,  one 

*  Baly's  Trans,  of  Miiller's  Physiology,  vol.  i.  p.  226. 


ILIO-LUMBAR   ARTERY.  317 

branch  is  distributed  on  the  dorsum  of  the  clitoris,  and  the 
other  terminates  in  its  corpus  cavernosum. 

Fig.  bb.— Represents  the  distribution  of  some  of  the  branches  of  the  Pudic  Artery 
in  the  Female. 


1,  The  Coccyx.  2,  2,  The  Tuberosities  of  the  Ischia.  3,  The  Mods  Veneris.  4,  The  left  Labium. 
6,  Clltoria.  6,  Prepuce  of  Clitoris.  7,  7,  The  Labia  Minora.  8,  Orifice  of  Urethra.  9,  Entrance 
to  Vagina.  10,  The  Anus.  11, 11,  Superficial  Sphincter.  12,  12,  The  Levatores  Ani  Muscles,  13,13, 
The  Transversalis  Alter  Muscle  of  each  side.  14,  14,  The  Transversales  Perinei  Muscles.  13,  15, 
Constrictor  of  Vagina.  16,  16,  The  Ischio  Cavernosa  Muscles.  17,  17,  The  Great  Gluta;i  Muscles. 
a.  Continuation  of  the  Internal  Pudic  Artery  of  the  right  side,  b,  b,  b,  h,  External  Hsemorrhoidal 
Arteries,  c,  Twig  passing  over  the  Tuberosity  of  the  Ischium,  d.  Deep  Perineal  Art«rv.  e,  Branch 
to  the  Great  Labium,  f,  f.  Artery  of  the  Clitoris,  g,  Continuation  of  Internal  Pudio  Artery  of  left 
side,    h,  Transverse  Artery  of  the  Perineum. 

We  shall  now  examine  the  branches  of  the  internal  iliac 
which  remain  within  the  pelvis. 

The  Ilio-Lumbar  Artery  arises  from  the  posterior  part 
of  the  internal  iliac,  and  takes  a  direction  upwards,  backwards, 
and  outwards  in  front  of  the  lumbo-sacral  nerve,  and  behind 
the  obturator  nerve  and  psoas  muscle ;  in  this  situation  it  di- 
vides into  its  two  principal  branches,  the  iliac  and  the  lumbar. 

The  Iliac  branch  takes  a  transverse  direction  beneath  the 
Anterior  crural  nerve  and  psoas  and  iliacus  internus  muscles ; 
some  of  its  branches  ramify  on  the  surface  of  the  muscle,  and 
others  in  a  more  deep-seated  situation.  From  the  latter 
branches  arises  the  nutritious  artery  of  the  ilium,  which  enters 

27* 


318 


ILIO-LUMBAR   ARTERY. 


the  canal  observable  near  the  centre  of  the  internal  iliac  fossa. 
The  Lumhar  branch  ascends  under  cover  of  the  psoas  muscle 
and  on  the  front  of  the  lumbo-sacral  nerve  :  one  of  its  branches 
enters  the  lateral  foramen  of  the  spine  between  the  j&fth  lum- 
bar vertebra  and  the  sacrum,  and  is  distributed  on  the  tunics 


Fig.  56. — Represents  a  lateral  view  of  the  Arteries  of  the  Pelvis  in  the  Male  subject. 
A  vertical  incision  has  been  carried  throughthe  Symphysis  Pubis,  the  middle  of  the 
Lumbar  Vertebrse,  and  the  Sacrum,.    The  Viscera  are  drawn  downwards. 


A,  Aorta.  B,  Left  Common  Iliac  Artery  divided.  C,  Right  Common  Iliac.  D,  External  Iliao. 
E,  Femoral  Artery.  F,  Internal  Iliac,  a,  Epigastric  Arterj'  cut.  b,  Internal  Circumtlexa  Ilii. 
c,  Twig  from  tlie  llio-lumbar  Artery,  d,  Vesical  Artery,  e,  Anterior  part  of  Internal  Iliac  Artery, 
f,  Internal  Pudic  Artery,  g,  Sciatic  Artery,  h,  Middle  Hicmorrhoidal  Artery  coming  from  the  Pudic, 
and  giving  off  vesical  twigs,  k,  Posterior  part  of  Internal  Iliac  Artery.  1,  Iliolumbar  Artery,  m, 
Obturator  Artery,  n^  Glutaeal  Artery,  o,  A  small  branch  pa.s.siug  into  the  first  Sacral  Foramen,  p, 
Lateral  Sacral  Artery  a  little  lower  down.  I,  Symphysis  Pubis.  2,  Anterior  Superior  Spine  of  the 
Ilium.  3,  Crest  of  the  Ilium.  4,  4,  Divided  last  two  Lumbar  Vertebrae.  5,  5,  Divided  Sacrum. 
6.  6,  Divided  spinous  processes  of  the  two  last  Lumbar  Vertebra;.  7,  Termination  of  the  Spinal 
Canal.  8,  Erector  Spinas  Muscle  of  the  right  side.  9,  Glutaeus  Maximus  Muscle.  10,  Rectum  divided, 
tied,  and  turned  down.  II,  Bladder  drawn  down.  12,  Anterior  Ligaments  of  the  Bladder. 
13,  Scrotum.  14,  Corpus  Cavernosum  of  the  left  side  divided.  15,  Sartorius  Muscle.  16,  Iliac  and 
Psoas  Muscle,  covered  by  17,  the  Iliac  Fascia. 


of  the  spinal  marrow ;  the  others  are  distributed  to  the  psoas 
and  quadratus  lumborum  muscles.  This  lumbar  branch  some- 
times arises  from  the  middle  sacral  artery. 

The  communications  of  the  ilio-lumbar  artery  are  extremely 
important :  its  lumbar  branch  communicates  with  the  proper 
lumbar  and  intercostal  arteries,  and  its  iliac  branch  communi- 
cates freely  at  the  crest  of  the  ilium  with  the  glutaeal,  circum- 


LATERAL  SACRAL  ARTERY.  319 

flexa  ilii,  and  external  circumflex  femoris  arteries.  This  ex- 
plains how  blood  is  freely  carried  to  the  extremities  when 
the  iliac  artery  or  lower  part  of  the  aorta  has  been  rendered 
impervious. 

The  Lateral  Sacral  Artery  descends  obliquely  in- 
wards on  the  front  of  the  sacral  plexus,  being  separated  from 
the  middle  sacral  by  the  trunk  of  the  sympathetic  nerve,  and 
covered  in  front  by  the  pelvic  viscera.  The  external  hranchesj 
usually  four  in  number,  enter  the  sacral  foramina  and  supply 
the  membranes  within  the  spinal  canal :  they  anastomose 
with  the  proper  spinal  arteries,  and  by  branches  which  pass 
through  the  posterior  sacral  foramina  communicate  with  the 
coccygeal  branch  of  the  sciatic  artery.  The  internal  hrancTies 
are  distributed  to  the  pelvic  viscera,  and  anastomose  with  the 
middle  sacral,  and  with  those  of  the  opposite  side.  The  in- 
ferior or  terminating  branch  communicates  in  the  form  of  an 
arch  with  the  corresponding  division  of  the  middle  sacral 
artery. 

The  Middle  Hemorrhoidal  Artery  descends  obliquely 
upon  the  anterior  and  lateral  parts  of  the  rectum,  which  it 
supplies.  It  communicates  superiorly  with  the  haemorrhoidal 
branches  of  the  inferior  mesenteric  artery,  and  inferiorly 
with  those  of  the  pudic. 

The  Vesical  Artery  arises  from  the  lowest  part  of  the 
internal  iliac,  immediately  before  the  latter  vessel  contributes 
to  form  the  superior  vesical  ligament.  It  accompanies  the 
ureter  to  the  inferior  region  of  the  bladder,  and  its  branches 
are  distributed  to  this  reservoir  and  to  the  prostate  gland, 
vesiculae  seminales,  and  urethra.  One  of  its  branches,  the 
deferential  artery,  has  been  particularly  mentioned  by  Sir  A. 
Cooper :  he  describes  it  as  the  "  second  artery''  in  the  sperma- 
tic cord,  the  spermatic  artery  being  the  first,  and  the  ere- 


320  UMBILICAL   AND    UTERINE   ARTERIES. 

masteric  the  third.  "It  takes  its  origin  from  the  vesical 
artery,  close  to  the  commencement  of  the  ligamentous  re- 
mains of  the  umbilical  artery  f  near  the  inferior  fundus  of 
the  bladder  it  "  divides  into  two  sets  of  branches,  one  set  de- 
scending to  the  vesicula  seminalis  and  to  the  termination  of 
the  vas  deferens ;  the  other,  ascending  upon  the  vas  deferens, 
runs  in  a  serpentine  direction  upon  the  coat  of  that  vessel, 
passing  through  the  whole  length  of  the  spermatic  cord ;  and 
when  it  reaches  the  cauda  epididymis,  it  divides  into  two  sets 
of  branches, — one  advancing  to  unite  with  the  spermatic 
artery,  to  supply  the  testicle  and  epididymis,  the  other 
passing  backwards  to  the  tunica  vaginalis  and  cremaster."* 

The  bladder  is  supplied  from  other  arteries  also,  viz.,  those 
given  off  by  the  pudic,  obturator,  and  middle  hasmorrhoidal. 
There  are  also  branches  given  off  by  the  umbilical  artery ; 
but  they  are  only  pervious  in  a  part  of  their  course. 

The  Umbilical  Artery. — This  vessel  is  merely  a  con- 
tinuation of  the  internal  iliac  artery  as  it  runs  along  the 
bladder  towards  the  umbilicus :  after  a  course  of  about  two 
inches  it  becomes  closed,  and  degenerates  into  the  ligament- 
ous remains  of  the  umbilical  artery,  which,  when  pervious  in 
the  foetus,  carried  the  blood  to  the  placenta.  This  artery 
gives  off  small  branches  to  the  bladder. 

The  Uterine  Artery  proceeds  to  the  superior  and  lateral 
parts  of  the  vagina  and  beneath  the  bladder.  Having  sup- 
plied these  parts,  it  ascends  on  the  side  of  the  uterus,  between 
the  folds  of  its  broad  ligament :  here  it  divides  into  several 
branches,  which  penetrate  its  structure  and  spread  in  a  tor- 
tuous manner  on  both  its  surfaces,  to  communicate  with  its 
fellow  of  the  opposite  side :  some  of  them  ascend  to  the 
round  ligament,  and  Fallopian  tubes,  and  anastomose  with 

*  "  Observations  on  the  Structure  and  Diseases  of  the  Testis,"  p.  33. 


EXTERNAL   ILIAC   ARTERY.  321 

the  spermatic  arteries ;  and  one  or  more  of  them  descend  on 
the  vagina.  These  arteries  are  remarkable  for  the  great  tor- 
tuosity of  all  their  branches,  even  the  smallest;  and  this 
character  they  preserve  when  they  become  greatly  enlarged, 
as  in  pregnancy. 

The  Vaginal  Artery  is  equal  in  size  to  the  uterine  in 
the  young  subject,  but  smaller  than  it  after  puberty.  It 
descends  on  the  side  of  the  vagina,  to  which  it  distributes 
several  branches.  It  also  sends  a  branch  to  the  bladder,  and 
supplies  the  external  organs  of  generation. 

external  iliac  artery. 
This  vessel  arises  from  the  common  iliac  nearly  opposite 
the  superior  extremity  of  the  sacro-iliac  symphysis,  and  de- 
scends obliquely  forwards  and  outwards  towards  the  centre  of 
Poupart's  ligament.  The  length  of  the  artery  varies  accord- 
ing to  the  situation  at  which  the  bifurcation  of  the  common 
iliac  takes  place :  generally  speaking,  however,  it  is  about 
three  and  a  half  or  four  inches  in  length.  Posteriorly^  it 
corresponds  to  the  external  iliac  vein,  which  separates  its 
origin  from  that  of  the  internal  iliac  artery,  the  vein  lying 
in  the  angle  between  the  two  arteries ;  and  farther  onwards, 
the  psoas  muscle  and  iliac  fascia  are  situated  behind  it.  On 
the  right  side  the  commencement  of  the  right  common  iliac 
vein  lies  posterior  to  it.  Anteriorly,  it  is  covered  by  the 
peritoneum,  and  near  Poupart's  ligament  by  the  circumflexa 
ilii  vein,  which  sometimes,  however,  passes  behind  it.  Ex- 
ternallyj  the  fascia  iliaca  and  some  fibres  of  the  psoas  muscle 
separate  it  from  the  anterior  crural  nerve,  which  lies  behind 
the  fascia,  deeply  imbedded  between  the  psoas  and  iliacus 
muscles :  a  branch  of  the  genito-crural  nerve  is  also  found 
running  along  the  artery  in  this  situation,  and  inclining  to 
its  anterior  surface.  Internally,  near  Poupart's  ligament,  we 
see  its  accompanying  vein,  lying  also  on  a  plane  posterior  to 


322     abernethy's  operation  on  the  external  iliac. 

the  artery;  and  on  the  inner  side  of  the  vein  we  may  ob- 
serve the  septum  crurale,  or  "fascia  propria"  of  Sir  A.  Cooper, 
lying  across  the  internal  opening  of  the  crural  canal.  On  a 
plane  posterior  to  the  artery,  in  the  male  subject,  the  vas 
deferens,  as  it  descends  into  the  pelvis,  lies  internal  to  it. 
The  artery  and  vein  will  be  found  surrounded  completely  by 
the  sub-peritoneal  layer  of  fascia  already  described.  The 
student  should  bear  in  mind  that  the  anterior  crural  nerve  is 
external  to  the  artery  and  on  a  deeper  plane ;  and  that  the 
external  iliac  vein  is  at  first  posterior,  and  afterwards,  near 
Poupart's  ligament,  becomes  internal  to  the  artery. 

Operation  of  tying  the  External  Iliac  Artei^. — Mr.  Aher- 
nethy's  method. — The  external  iliac  artery  was  first  tied  by 
Mr.  Abernethy,  in  the  year  1796,  in  a  case  of  femoral 
aneurism.  He  had  previously  tied  the  femoral  artery, 
according  to  Brasdor's  plan,  on  the  capillary  side  of  the 
aneurism;  but,  dangerous  hemorrhage  having  occurred  on 
the  fifteenth  day  after  the  operation,  he  proceeded  to  tie  the 
external  iliac  artery. 

Having  separately  divided  the  integuments  and  aponeu- 
rosis of  the  external  oblique  muscle,  for  about  three  inches 
in  extent  over  the  course  of  the  artery,  he  next  passed  his 
finger  beneath  the  margin  of  the  internal  oblique  and  trans- 
versalis  muscles,  and  divided  them  in  the  same  direction. 
The  peritoneum  being  next  pushed  upwards  and  inwards,  he 
proceeded  to  separate  the  vein  from  the  artery.  In  this, 
however,  as  already  stated,  much  difficulty  was  experienced 
until  the  fascia,  which  covered  and  united  them,  was  divided; 
this  was  done  with  much  caution,  and  a  ligature  passed  round 
the  artery  from  within  outwards.  In  his  next  case  he  pro- 
ceeded in  a  similar  way,  except  that  he  made  his  incision  not 
over,  but  in  a  line  a  little  external  to,  the  course  of  the  artery, 
in  order  to  avoid  the  epigastric.  In  both  these  cases  he 
failed;  but  in  the  third,  in  1806,  the  patient  perfectly  reco- 


cooper's  operation  on  the  external  iliac.      323 

vered.  Mr.  Freer,  of  Birmingham,  performed  the  operation 
in  1806 ;  Mr.  Tomlinson  operated  in  1807,  and  in  a  second 
instance  in  1809, — in  both  cases  with  success.  In  1811,  the 
operation  of  tying  this  artery  with  a  single  ligature  was 
successfully  performed  in  this  city  by  the  late  Mr.  Kirby. 
During  the  operation  he  experienced  the  same  difficulty  from 
the  sub-peritoneal  layer  of  fascia  that  Mr.  Abernethy  encoun- 
tered in  his  operation.*  In  1814  Sir  A.  Cooper  had  performed 
this  operation  seven  times,  and  four  out  of  seven  cases  were 
successful.  The  artery  has  also  been  tied  in  this  city  by  Todd, 
Wilmot,  Porter,  Houston,  Bellingham,  &c. :  in  all,  it  has  been 
tied  about  forty-three  times  for  aneurism  of  the  femoral  artery.f 

Sir  A.  Cooper's  Operation  on  the  External  Iliac  Artery. — 
"A  semilunar  incision  is  made  through  the  integuments  in 
the  direction  of  the  fibres  of  the  aponeurosis  of  the  external 
oblique  muscle.  One  extremity  of  this  incision  will  be  situ- 
ated near  the  spine  of  the  ilium ;  the  other  will  terminate  a 
little  above  the  inner  margin  of  the  abdominal  ring.  The 
aponeurosis  of  the  external  oblique  muscle  will  be  exposed, 
and  is  to  be  divided  throughout  the  extent  and  in  the  direc- 
tion of  the  external  wound.  The  flap  which  is  thus  formed 
being  raised,  the  spermatic  cord  will  be  seen  passing  under 
the  margin  of  the  internal  oblique  and  transverse  muscles. 
The  opening  in  the  fascia  which  lines  the  transverse  muscle, 
and  through  which  the  spermatic  cord  passes,  is  situated  in 
the  mid-space  between  the  anterior  superior  spine  of  the 
ilium,  and  the  symphysis  pubis.  The  epigastric  artery  runs 
precisely  along  the  inner  margin  of  this  opening,  beneath 
which  the  external  iliac  artery  is  situated.  If  the  finger, 
therefore,  be  passed  under  the  spermatic  cord,  through  this 
opening  in  the  fascia,  it  will  come  into  immediate  contact 


*  "  Cases  in  Surgery  by  John  Kirby,"  p.  104^. 

f  Crisp  on  the  Structure,  Diseases,  Ac.  of  the  Blood- Vessels,  p.  22G. 


324  LIGATURE   OF   THE   EXTERNAL   ILIAC. 

with  the  artery,  which  lies  on  the  outside  of  the  external 
iliac  vein.  The  artery  and  vein  are  connected  by  dense  cel- 
lular tissue,  which  must  be  separated,  in  order  to  allow  of  the 
ligature  being  passed  round  the  former."* 

According  to  Mr.  Abernethy's  method,  two-thirds  of  the 
longitudinal  incision  are  made  over  a  portion  of  peritoneum 
which  closely  lines  the  abdominal  muscles,  and  does  not  re- 
quire to  be  separated:  it  is  therefore  uselessly  endangered. 
Moreover,  the  division  of  the  muscles  in  this  direction  weakens 
the  abdominal  parietes,  and  gives  a  tendency  to  the  formation 
of  hernia,  which  occurred  in  Mr.  Kirby^s  case.  For  these 
reasons  Sir  A.  Cooper's  operation  is  generally  preferred.  It 
has  been  said  that  Mr.  Abernethy's  mode  gives  greater  faci- 
lity of  tying  the  artery  high  up  if  necessary ;  but  this  can  be 
equally  well  effected  by  enlarging  the  external  angle  of  the 
incision,  recommended  by  Sir  A  Cooper. 

In  either  operation  the  greatest  care  should  be  taken  that 
no  injury  be  done  to  the  peritoneum.  In  Dr.  Post's  prac- 
tice, however,  an  instance  occurred  in  which  this  membrane 
was  so  thickened  by  disease  that  he  could  not  detach  it,  but 
was  obliged  to  make  an  opening  in  it,  and  include  a  part  of  it 
in  the  ligature.  The  surgeon  should  attend  also  to  the  origin 
and  course  of  the  epigastric  artery  in  relation  to  this  opera- 
tion. Dupuytren  lost  a  patient  by  wounding  it;  and  Beclard, 
by  tying  the  iliac  immediately  beneath  its  origin^  so  that  suffi- 
cient room  was  not  left  for  the  formation  of  a  coagulum :  in 
some  cases  this  vessel  arises  six  or  eight  lines  higher  up  than 
usual,  and  the  operator  should  therefore  search  for  its  origin, 
and  apply  the  ligature  above  it.  The  proximity  of  the  vas 
deferens  and  the  femoral  branch  of  the  genito-crural  nerve  to 
the  artery  are  also  to  be  borne  in  mind 

When  the  trunk  of  the  external  iliac  artery  is  tied,  the 
limb  is  abundantly  supplied  with  blood  by  the  branches  of 

*  Hodgson  on  the  Arteries  and  Veins,  p.  421. 


LIGATURE    OF   THE   EXTERNAL   ILIAC.  325 

the  internal  iliac  in  the  following  manner  : — the  gluteal 
branch  of  the  internal  iliac  transmits  blood  to  the  femoral 
artery,  through  the  internal  and  external  circumflex  branches 
of  the  latter :  the  sciatic  artery  transmits  blood  to  the  femo- 
ral by  the  internal  circumflex  and  perforating  arteries ;  and 
to  the  popliteal  through  the  comes  nervi  ischiatici  :*  (Boyer 
mentions  an  instance  where  this  small  branch,  eight  months 
after  the  operation  for  popliteal  aneurism,  had  attained  the 
size  of  the  radial  artery  at  the  wrist :)  the  obturator  artery 
supplies  the  femoral  through  the  branches  which  communi- 
cate with  the  internal  circumflex :  lastly,  the  jpudic  artery 
supplies  the  femoral  by  its  communication  with  the  pudic 
branches  of  the  latter. 

Upon  examining  the  limb  on  which  the  operation  of  tying 
the  external  iliac  has  been  performed,  we  find  that  the  por- 
tion of  the  femoral  artery  below  the  origin  of  the  profunda  is 
unchanged  in  calibre ;  while  that  portion  between  the  origin 
of  the  profunda  and  the  ligature  may  either  remain  the  natu- 
ral size,  as  in  Mr.  Norman's  case,"]"  or  it  may  be  contracted,  as 
in  Sir.  A.  Cooper's  case,J  in  which  the  vessel,  in  this  situa- 
tion, was  found  reduced  to  one-half  its  size. 

The  late  Mr.  Wilmot  has  observed,  "that  the  recoveries 
after  this  operation  (ligature  of  the  external  iliac  artery) 
have  been  more  frequent,  in  proportion  to  the  numbers  ope- 
rated upon,  than  after  tying  the  femoral  artery  for  popliteal 
aneurism.' '§ 

The  external  iliac  artery  gives  off  two  branches,  viz.,  the 

Epigastric  and  Internal  Circumflexa  Ilii ; 
and  then  terminates  in  the  Femoral. 


*  See  Med.  Chirurg.  Trans.,  vol.  iv.,  and  Guy's  Hospital  Reports,  No.  1, 
Jan.  1836. 

f  Med.  Chirurg.  Trans.,  vol.  xx. 
J  Guy's  Hospital  Reports. 
§  Dub.  Hosp.  Report,  vol.  ii.  p.  214. 
28 


826 


INTERNAL    MAMMARY   AND   EPIGASTRIC. 


Pig.  67. — Represents  the  course  of  the  Internal  Mammary  and  the  Epigastric  Arte- 
ries. At  the  right  side  the  muscles  have  been  partially  removed,  in  order  to  expose 
the  anastomosis  between  these  vessels. 


A,  External  Iliac  Artery.  B,  Femoral  Artery,  a.  a,  Costal  Cartilages,  b,  b,  Perforating  branches 
of  the  Internal  Mammary  Artery,  c,  c,  c,  c,  o,  Anterior  Intercostal  branches  of  the  Internal  Mam- 
mary, d,  d,  e,  e,  e,  External  Intercastal  branches,  g,  Anastomosis  between  the  Internal  Mammary 
and  Epigastric  Arteries,  h,  Epigastric  Artery,  i,  Internal  Circumtlexa  Ilii  Artery,  k,  k,  1,  Twigs 
from  the  Circumflexa  Ilii  Artery,  m,  m,  External  Circumflexa  Ilii.  n,  Superficial  Epigastric  Ar- 
tery from  the  Femoral,  o.  Glandular  twigs  from  the  Femoral.  P,  Superficial  Pudic  Branch,  q, 
Spermatic  Artery,  r,  Long  Thoracic  Artery.  I,  I,  The  Sternum.  2,  Xiphoid  appendix.  3,  3,  Cla- 
vicles. 4,  Deltoid  Muscle.  5,  Gi-eat  Pectoral  Muscle.  6,  Subclavius  Muscle.  7,  Portion  of  Lesser 
Pectoral  Muscle,  8,  8,  Serratiis  Magnus  Muscle.  9.  Latissimus  Dorsi  Muscle.  10,  10,  External  Ob- 
lique Muscle.  11,  11,  Linca  Alba.  12,  Transvcrsalis  Abdominis  Muscle.  13,  Peritoneum.  14,  Por- 
tion of  Internal  Oblique  and  Transvcrsalis  Abdominis — the  dotted  lines  show  the  course  of  the  Epi- 
gastric Artery  in  this  region.  15,  Pyramidalis  Abdominis.  IB,  Anterior  Superior  Spine  of  Ilium. 
17,  Pouparfs  Ligament.  18,  18,  Superficial  Inguinal  Glands.  19,  Vas  Deferen'i.  20,  Sartorius 
Muscle.    21,  Tensor  Vaginse  Femoris,    22,  Glutseua  Medius 


EPIGASTRIC  ARTERY.  327 

The  Epigastric  Artery  arises  from  the  external  iliac, 
usually  about  three  or  four  lines  above  Poupart's  ligament : 
from  this  origin  it  takes  a  direction  forwards,  inwards,  and 
slightly  downwards,  crossing  anterior  to  the  external  iliac 
vein :  it  next  turns  upwards  and  inwards,  so  as  to  form  a  cur- 
vature, the  convexity  of  which  is  directed  downwards,  look- 
ing towards  Poupart's  ligament,  and,  in  some  cases,  even 
sinking  into  the  femoral  ring ;  the  concavity  looks  upwards, 
and  lodges  a  cul  de  sac  of  the  peritoneum.  We  next  trace 
the  artery  ascending  obliquely  inwards,  between  the  fascia 
transversalis  in  front  and  the  peritoneum  posteriorly,  in  order 
to  arrive  at  the  inner  margin  of  the  internal  abdominal  ring. 
In  this  situation  the  vas  deferens  hooks  round  it,  having  first 
passed  upwards  and  outwards,  to  the  ring  in  front  of  the 
artery ;  and  then  downwards  and  inwards,  to  the  pelvis  behind 
it.  From  the  inguinal  ring,  the  epigastric  artery  continues 
to  ascend  obliquely  inwards,  till  it  gets  between  the  posterior 
surface  of  the  rectus  muscle  and  its  sheath  j  this  latter  struc- 
ture presents  at  its  termination  inferiorly  a  lunated  margin 
more  or  less  distinct,  and  it  is  corresponding  to  this  situation 
that  we  find  the  artery  of  each  side  entering  the  sheath. 
Finally  the  epigastric  artery  terminates  by  anastomosing  with 
the  internal  mammary  artery. 

The  branches  of  the  epigastric  are :  the  spermatic  or  cre- 
masteric branch,  which  descends  with  the  spermatic  cord,  to 
be  lost  on  the  coverings  of  the  testicle :  a  branch  which 
crosses  behind  the  symphysis  pubis,  to  anastomose  with  a 
similar  branch  from  the  opposite  side ;  and  an  obturator 
branch,  which  descends  behind  the  transverse  ramus  of  the 
pubis,  to  anastomose  with  the  obturator  artery.  It  also  gives 
several  branches  to  the  oblique  muscles  of  the  abdomen, 
some  of  which  are  of  considerable  size,  and  fatal  hemorrhage 
has  been  known  to  arise  from  a  wound  of  one  of  them,  in 
tapping  the  abdomen.     Lastly,  the  epigastric  artery  termi- 


828  FEMORAL   ARTERY. 

nates  in  anastomosis  with  the  internal  mammary  in  the  sub- 
stance of  the  rectus  muscle  as  well  as  within  its  sheath. 

The  Epigastric  Vein  arises  from  the  external  iliac  close  to 
Poupart's  ligament^  and  ascends  on  the  inside  of  the  epigas- 
tric artery ;  it  then  bifurcates^  and  the  artery  lies  between  its 
divisions. 

The  Internal  Circumflexa  Ilii  Artery,  smaller  than  the  pre- 
ceding, usually  arises  a  little  beneath,  and  sometimes  oppo- 
site to  it :  immediately  after  its  origin  it  pierces  the  junction 
of  the  fascia  transversalis  and  fascia  iliaca,  crossing  over  a 
small  pouch  or  depression  which  we  may  observe  between  the 
outer  side  of  the  external  iliac  artery  and  the  lunated  margin 
of  the  fasciae  at  their  junction )  it  then  takes  a  direction  up- 
wards, backwards,  and  outwards,  corresponding,  not  to  Pou- 
part's ligament,  as  usually  represented,  but  to  a  white  line 
which  marks  the  junction  of  the  two  fasciae :  this  line  is  a 
little  above  and  behind  Poupart's  ligament.  Having  ar- 
rived near  the  anterior  superior  spine  of  the  ilium,  it  termi- 
nates by  dividing  into  two  branches,  one  of  which  supplies 
the  broad  muscles  of  the  abdomen,  and  anastomoses  with  the 
inferior  intercostal  and  lumbar  arteries ;  the  other  continues 
in  the  direction  of  the  trunk,  and,  having  arrived  at  the  an- 
terior superior  spine  of  the  ilium,  terminates  in  anastomosing 
with  the  superficial  circumflexa  ilii,  the  external  circumflexa 
femoris,  the  glutaeal,  and  ilio-lumbar  arteries. 

The  Circumflexa  Ilii  Vein  comes  from  the  external  iliac, 
and  usually  crosses  in  front  of,  sometimes  behind,  the  external 
iliac  artery,  to  arrive  at  its  destination  in  the  external  iliac 
vein. 

THE  FEMORAL  ARTERY. 

This  vessel,  called  by  some  the  superficial  femoral  artery, 
commences  behind  Poupart's  ligament,  and  loses  the  name  of 
femoral  after  having  passed  through  a  tendinous  opening  in 
the  adductor  magnus  muscle,  when  it  receives  the  name  of 


FEMORAL  ARTERY. 


329 


popliteal.  Professor  Al- 
cock  refers  the  com- 
mencement of  the  femo- 
ral artery  to  a  fixed  point, 
namely,  "the  ilio-pecti- 
neal  eminence  of  the 
OS  innominatum,"  corre- 
sponding to  a  point  mid- 
way between  the  spinous 
process  of  the  ilium  and 
the  symphysis  pubis.* 
Its  course  is  nearly  paral- 
lel to  a  line  drawn  from 
a  point  a  little  internal  to 
the  centre  of  Poupart^s 
ligament  to  the  internal 
margin  of  the  patella. 
According  to  Professor 
Alcock,  though  for  the 
most  part  the  artery  in- 
clines inwards  at  first, 
that  is,  from  the  os  in- 
nominatum  into  the  in- 
guinal space,  yet,  "the 
general  direction  of  it  is 


Fig.  58. — Arteries  of  tlie  front 
of  the  Thigh. 

1,  Femoral  Artery.  2,  Popliteal  Ar- 
tery, 3,  Posterior  Tibial  Artery.  4, 
Superficial  Kpjgastrio  Artery.  5,  Su 
perficial  Circumtiex  Iliac.  6,  External 
Pudics.  7,  Profound  Femoral  Artery-. 
8,  9,  External  and  Internal  Circumflex 
Arteries.  10,  Perforating  Arteries.  11, 
Muscular  Brandies.  12,  Anastomotic 
Artery.  13,  H,  Internal  Articular  Ar- 
teries. 15,  Small  Brancli  from  the  Epi- 
gastric. 16,  Dorsal  Arteries  of  the  Pe- 
nis, a,  Rectus  Muscle.  6,  Internal 
Vastus,  c,  d,  e,  Adductor  Muscles.  /, 
Serai-tendinous  Muscle,  g,  Sartorius 
Muscle. 


*  Todd's  Cyclopasdia,  p.  2.36. 
28* 


330 


FEMORAL   ARTERY. 


either  slightly  outward,  or  at  the  most  directly  downward,  not 
inward."*  It  is  at  first  on  a  plane  anterior  to  the  femur,  but 
soon  becomes  internal,  and  lastly,  where  it  becomes  the  popli- 
teal artery,  it  lies  posterior  to  this  bone. 

In  the  superior  third  of  the  thigh  it  is  covered  by  the 
integuments,  then  by  the  superficial  fascia;  and  on  removing 
this  layer  of  parts  we  expose  the  fascia  lata  of  the  thigh, 
which  in  this  region  is  arranged  in  the  following  divisions  or 
layers,  viz.,  the  iliac,  cribriform,  and  pectineal  or  pubic.    The 


Fig. 


-Tlie  Surgical  Anatomy  of  the  Inguinal  Region, 
partly  removed. 


The  Fascia  Lata  has  been 


A,  Muscular  part  of  External  Oblique.  B.  The  Umbilicus.  C,  Tlie  Anterior  Superior  Iliac  Spine. 
D,  The  Spine  of  the  Pubis.  K,  The  Cremaster.  F,  The  luiernal  Oblique,  G.  The  Linea  Alba.  H, 
The  Iliac  portion  of  the  Fascia  Lata.  1.  The  Femoral  Vein.  K.  Tlie  Femoral  Artery.  L,  The  An- 
terior Crural  Norve.  M,  The  Saitorius  Muscle.  N,  The  Anterior  wall  of  the  Funnel  partially  dis- 
sected away  from  the  vessels.  The  Septum  formed  by  the  sheath  and  dipping  in  between  the  ariery 
and  vein,  attaching  itself  anteriorly  to  the  anterior  wail  of  the  Funnel,  and  posteriorly  to  the  pos- 
terior w^all,  is  here  exhibited.  O,  The  Saphena  Vein.  P.  The  Pubic  portion  of  (he  Fascia  Lata, 
a,  a,  The  tendon  of  the  llxternal  Oblique,    g,  The  Linea  Semilunaris,    h,  Hey  s  Ligament. 


*  Todd's  Cyclopaedia,  p.  23G. 


FEMORAL  ARTERY.  331 

middle  or  cribriform  portion  crosses  the  saphenic  opening  or 
anterior  inferior  termination  of  the  crural  canal,  and  lies  an- 
terior to  the  femoral  artery  and  vein.  The  external  margin 
of  the  saphenic  opening  is  formed  by  the  iliac  portion  of  the 
fascia  lata,  and  presents  a  lunated  appearance,  the  concavity 
of  which  is  directed  inwards,  and  unites  with  the  cribriform 
layer,  and  in  this  situation  covers  a  portion  of  the  artery: 
above  this  point  we  may  observe  the  iliac  portion  of  the  fascia 
lata  passing  upwards  and  inwards  to  form  Hey's  ligament, 
the  commencement  of  which  also  lies  anterior  to  the  artery ; 
this  ligament,  as  it  passes  inwards  to  its  insertion,  forms  also 
an  anterior  relation  to  the  femoral  vein.  The  pectineal  or 
pubic  portion  of  the  fascia  lata  may  be  traced  outwards  from 
the  pubis,  and  will  be  found  to  form  an  inclined  plane  which 
passes  behind  the  vessels.  When  the  iliac  and  cribriform 
portion  of  the  fascia  lata  have  been  carefully  removed,  the 
femoral  prolongation  of  the  fascia  transversalis  will  be  brought 
into  view :  the  fascia  transversalis  is  exceedingly  thin  in  this 
situation,  and  by  a  careful  dissection  can  be  seen  passing  up- 
wards behind  Poupart's  ligament  to  the  abdomen,  externally 
forming  a  connection  with  the  fascia  iliaca,  close  to  the  outer 
side  of  the  external  iliac  artery,  and  internally  correspond- 
ing to  the  base  of  Gimbernaut's  ligament,  connected  with  the 
same  fascia.  It  will  be  seen  presently  that  the  fascia  iliaca 
descends  behind  the  vessels  in  the  same  manner  as  the  fascia 
transversalis  does  in  front.  Both  of  these  fasciae  thus  form  a 
pyramidal  or  funnel-shaped  investment  for  the  artery  and 
vein;  wide  superiorly  towards  the  abdomen,  and  narrow 
inferiorly,  where  the  two  fasciae  become  inseparably  identified 
with  the  proper  sheath  of  the  vessels.  Some  confusion  has 
arisen  from  the  names  given  to  these  prolongations  of  the 
fasciae  from  the  abdomen  and  pelvis.  Sir  A.  Cooper,  in 
speaking  of  the  fascia  transversalis  and  fascia  iliaca  as  related 
to  the  femoral  artery  and  vein,  says  that  they  form  the 
"  crural  sheath/'  or  "  the  sheath  in  which  the  crural  vessels 


332  FEMORAL   ARTERY. 

are  contained;"  and  again,  "the  sheath  is  therefore  formed 
like  a  funnel."  If  we  cautiously  remove  the  fascia  transver- 
salis  and  the  fascia  iliaca  from  the  vessels,  it  will  be  distinctly 
seen  that  they  have  still  a  well-marked  sheath  surrounding 
them,  which,  as  has  been  already  indicated,  is  a  prolongation 
of  the  sub-peritoneal  layer  of  tissue  which  forms  a  proper 
sheath  for  the  external  iliac  artery  and  vein :  it  would  appear, 
therefore,  that  the  term  sheath  of  the  vessels  might  be  more 
correctly  applied  to  this  latter  structure,  and  the  term  "  fun- 
nel" might  with  equal  propriety  be  confined  to  the  investment 
formed  by  fascia  transversalis  and  fascia  iliaca.  On  gently 
passing  the  handle  of  the  scalpel  downwards  between  the 
vessels  and  the  anterior  part  of  funnel,  we  will  remark  that 
the  fascia  transversalis  identifies  itself  with  the  sheath  of  the 
vessels  higher  up,  that  is,  nearer  to  Poupart's  ligament,  on 
the  front  of  the  artery  than  on  the  vein :  the  connection 
between  the  anterior  wall  of  the  funnel  and  the  sheath  passes 
obliquely  downwards  and  inwards,  and  extends  as  far  down 
along  the  femoral  vein  as  the  entrance  of  the  saphena  vein : 
there  is  therefore  more  of  the  vein  than  of  the  artery  con- 
tained within  the  funnel. 

In  this  stage  of  the  dissection  it  will  be  observed  that 
within  the  funnel,  and  throughout  its  length,  the  artery  and 
vein  do  not  lie  in  contact  with  one  another,  but  are  separated 
from  each  other  by  a  more  or  less  strong  and  thickened  por- 
tion of  the  sheath :  a  similar  structure  exists  also  along  the 
outer  side  of  the  artery,  and  along  the  inner  side  of  the  vein : 
these  partitions  are  attached  anteriorly  to  the  fascia  transver- 
salis, and  posteriorly  to  the  fascia  iliaca.  The  artery  and  vein 
are  thus  lodged  in  two  separate  and  distinct  compartments  of 
the  sheath ;  a  similar  arrangement  has  been  already  noticed 
when  speaking  of  the  carotid  artery  and  internal  jugular  vein. 

The  posterior  surface  of  the  artery  is  applied,  first,  upon 
the  anterior  surface  and  inner  portion  of  the  psoas  magnus 
muscle,  with  the  intervention  of  the   posterior  wall  of  the 


FEMORAL   ARTERY.  333 

funnel  or  femoral  prolongation  of  the  fascia  iliaea,  and  the 
deep  layer  of  the  iliac  portion  of  the  fascia  lata,  and  on  part 
of  the  anterior  surface  of  the  capsule  of  the  hip-joint:  it  then 
descends  in  front  of  the  pectineus  muscle,  but  separated  from 
it  by  the  profunda  artery  and  the  profunda  and  femoral  veins 
and  the  pectineal  portion  of  the  fascia  lata.  Between  the 
pectineus  muscle  and  adductor  longus  there  is  sometimes  an 
interval  in  which  the  femoral  artery  corresponds  to  the  ad- 
ductor brevis.  In  this  region  the  artery  is  lodged  in  a  pris- 
matic space,  bounded  anteriorly  by  the  anterior  relations  of 
the  artery  which  form  the  base ;  internally  by  the  pectineal 
or  pubic  portion  of  the  fascia  lata,  and  by  the  pectineus  and 
adductor  brevis  muscles;  externally  by  the  psoas  and  iliacus 
internus  muscles,  and  by  the  upper  part  of  the  vastus  inter- 
nus  :  the  apex  corresponds  posteriorly  to  the  convergence  of 
the  internal  and  external  boundaries.  Superiorly  this  space 
receives  the  parts  which  enter  it  from  the  abdomen  behind 
the  crural  arch ;  and  inferiorly  it  terminates  in  another  pris- 
matic channel,  called  the  Hunterian  canal.  Previously  to 
its  entering  into  this  canal,  the  artery  is  covered  by  the  sar- 
torius  muscle,  with  the  interposition  of  a  strong  aponeurosis. 
This  aponeurosis  commences  in  a  gradual  manner,  imme- 
diately below  Scarpa's  angle,  and  terminates  abruptly  opposite 
the  origin  of  the  anastomotica  magna  artery :  its  fibres  are 
distinct,  and  run  obliquely  downward  and  outwards.  After 
the  removal  of  the  superficial  relations  of  the  femoral  artery, 
and  before  examining  its  deep-seated  relations  in  the  upper 
third  of  the  thigh,  we  observe  a  comparatively  superficial  tri- 
angular space,  called  Scarpa's  space  or  angle,  which  contains 
the  artery  and  vein :  it  is  bounded  by  the  sartorius  muscle  on 
the  outside,  and  the  adductors  on  the  inside;  the  conver- 
gence of  these  muscles  below  forms  the  apex,  and  the  base  is 
formed  superiorly  by  Poupart's  ligament.  When  the  femoral 
artery  passes  under  the  sartorius  muscle,  it  becomes  lodged  in 
the  Hunterian  canal;  this  canal  occupies  the  middle  third  of 


334  FEMORAL   ARTERY. 

Fig.  GO.—Heprestnts  the  Arteries  on  the  Anterior  Aspect  of  the  Tliigh. 


1,  The  Bifurcation  of  the  Aorta  into  the  Common  Uiacs.  2,  The  Middle  Sacral  Artery.  3,  The 
Urinary  Bladder.  4.  The  Symphysis  Pubis.  5,  Suspensory  Ligament  of  the  Penis.  6.  the  Penis. 
7,  External  Oblique  Muscle  of  Abdomen.  8,  The  Crural  Arch.  9.  The  Kxtemal  Abdominal  Ring. 
10,  The  Spermatic  Cord.  11,  11,  The  Scrotum.  12,  The  skin  of  the  Penis  cut  and  turned  over.  13. 
The  Prepuce.  14, 14,  The  Glutajus  Medius  Muscle  of  each  side.  15,  15,  The  Tensor  Vaginae  Femoris 
of  each  side.  16,  16,  The  Sartorius.  17, 17,  The  lliacus  Internus,  18,  18.  The  Psoas  Magnus.  19,  19. 
Pectineus.  20,  20,  Adductor  Longus.  21,  21,  The  Gracilis.  22,  22,  22,  The  Rectus.  23,  23.  The 
Vastus  Externus.  24,  24,  The  Vastus  Internus.  25,  The  Patella.  26,  26,  The  Ligaraentum  Patellae. 
27,  The  Tibialis  Amicus.  28,  Extensor  Communis  and  Peroneus  Longus.  29,  Internal  portion  of 
Gastrocnemius.  30,  Adductor  Magnus.  31,  Right  Common  Iliac  Artery.  32,  32,  Femoral  Artery. 
33.  34,  External  Circuratiexa  Ilii.  35,  The  Superficial  Epigastric,  which  in  this  case  came  from  the 
preceding  vessel.  36.  36,  The  External  Pudic  Vessels.  37,  The  Profunda.  38,  The  Femoral  Artery. 
39,  39,  Twigs  from  the  Internal  Circumttex.  40,  40,  Descending  Branch  from  the  External  Circum- 
flex. 41.  Twig  from  the  External  Circumflex  to  the  Tensor  Vaginae  Femoris.  42.  Muscular  Branch 
from  the  Femoral.    43,  43,  Muscular  Twigs  from  the  Femoral.    44,  Superficial  Branches  of  the  Anas- 


FEMORAL   ARTERY.  335 

the  thigh,  and  is  about  four  inches  or  four  inches  and  a  half 
in  length,  and  of  a  prismatic  form;  its  lateral  boundaries  are 
the  vastus  internus  on  the  outside,  and  the  adductor  longus 
on  the  inside;  the  apex  is  situated  posteriorly,  and  is  formed 
by  the  conjoined  tendons  of  the  vastus  internus  and  adductor 
longus  muscles  :  the  hase  of  this  prismatic  canal  is  placed  in 
front  of  the  femoral  artery,  and  is  formed  by  a  strong  aponeu- 
rotic structure,  chiefly  composed  of  short  transverse  fibres, 
which  connects  the  adductor  longus  with  the  vastus  internus, 
and  which  commences  superiorly  under  cover  of  the  sartorius 
muscle.  Within  this  canal  we  find  the  femoral  artery,  femo- 
ral vein,  and  two  or  three  branches  of  the  anterior  crural 
nerve;  one  of  these  branches  becomes  the  proper  internal 
saphenous  nerve.  Though  the  nerves  are  situated  within  the 
canal,  they  are  not  contained  within  the  proper  sheath  of  the 
vessels  which  binds  the  artery  and  vein  together.  The  in- 
ternal surface  of  the  Hunterian  canal  presents  a  shining  ten- 
dinous appearance. 

The  Femoral  Vein  is  at  first  placed  on  the  inside  of  the 
artery,  and  on  a  plane  posterior  to  it.  Opposite  Poupart's 
ligament,  it  lies  in  front  of  the  pectineus  muscle  and  the 
inner  edge  of  the  psoas,  but  on  arriving  at  the  origin  of 
the  profunda,  it  begins  to  get  behind  its  artery,  and  so  re- 
mains, projecting  a  little  to  its  outside  inferiorly. 

The  Ayiterior  Crural  Nerve^  opposite  Poupart's  ligament, 
lies  in  the  groove  between  the  psoas  and  iliacus  muscles, 
separated  from  the  artery  by  some  of  the  fibres  of  the  psoas 
muscle,  and  by  the  iliac  fascia  which  covers  the  nerve  and 

tomotica  Magna  Artery.  45,  45,  Muscular  Twig  from  same  vessel.  46,  Twig  to  the  Patella.  47, 
Terminating  twigs  of  the  Superior  External  Articular  Arterj-.  48,  Twig  from  the  Tibial  Recurrent 
Artery.  49,  Arterial  Anastomosis  over  the  Patella.  50,  The  Cremasteric  branch  of  Kpigastric.  51, 
Spermatic  Cord,  cut.  52,  CruriEus  Muscle.  53,  Aponeurotic  Opening  in  the  Adductor  Magnus,  with 
the  Anastomotica  Magna.  54,  Semi-membranosus.  55,  Twig  from  the  Anastomotica  Magna.  56,  Ten- 
diuous  expansion  over  the  Knee,  cut  and  turned  forward.  57,  Internal  portion  of  Gastrocnemius. 
58,  Internal  Iliac  Artery,  59,  59.  Branches  of  the  Ilio-lumbar  Artery.  60,  Tlie  External  Iliac  Artery. 
61,  The  Epigastric  Artery.  62,  Cremasteric  Artery.  63,  Internal  CircumHexa  Ilii.  64,  External 
CircumHex.  65,  Ascending  branch  of  preceding  artery.  66.  Muscular  twig  for  the  Quadriceps.  67, 
First  Perforating  Artery.  68,  The  Second  Perforating  Artery.  69,  Profunda  passing  behind  Ad- 
ductor Longus.  70,  The  Femoral  Artery  displaced  inwards  to  show  the  Profunda.  71,  Muscular  twig 
from  the  Femoral  for  the  Adductors.  72,  Muscular  twig.  73,  Anastomotica  Magna.  74,  Branch 
from  the  preceding  vessel  running  through  the  Vastus  Internus;  the  muscle  Is  partly  divided,  to 
show  this  course.  73,  Superior  Internal  Articular  Artery.  76,  The  Inferior  Internal  Articular 
Artery.    77,  The  Patellar  Arterial  Anastomosis.    78,  Sural  Artery. 


336  OPERATIONS   ON   THE   FEMORAL   ARTERY. 

lies  behind  the  artery.  Three  branches  of  this  nerve  are 
related  to  the  artery  in  its  course  down  the  thigh.  One  of 
them  accompanies  the  sartorius  muscle,  and  is  lost  at  the  in- 
side of  the  knee-joint;  the  second  is  the  internal  saphenous 
nerve  ;  at  first  it  lies  external,  and  afterwards  crosses  in  front 
of  the  artery,  running  at  the  same  time  inwards  as  it  descends 
in  the  thigh;  it  then  accompanies  the  anastomotic  artery, 
and  lastly  the  saphena  vein :  the  third  branch  descends  on 
the  outside  of  the  artery,  and  drops  near  the  middle  of  the 
thigh  into  the  vastus  internus  muscle.  The  second  and  third 
branches  are  contained  within  the  Hunterian  canal,  but  riot 
within  the  sheath  of  the  vessels. 

Operations  on  the  Femoral  Artery. — The  usual  circum- 
stances requiring  ligature  of  the  femoral  artery  are  wounds 
of  that  vessel,  or  aneurism  in  the  popliteal  region.  Mr. 
Hunter  was  the  first  who  tied  the  femoral  artery  for  popliteal 
aneurism.  This  operation  was  performed  in  the  year  1785. 
His  first  incision  was  made  through  the  integuments  of  the 
anterior  and  inner  part  of  the  thigh,  a  little  below  its  middle, 
so  as  to  cross  somewhat  obliquely  the  internal  margin  of  the 
sartorius  muscle  :  the  muscle  being  turned  outwards,  the 
fascia  covering  the  artery  was  exposed  and  divided,  so  as  to 
bring  the  femoral  vessels  lying  within  the  Hunterian  canal 
into  view.  The  artery  having  been  disengaged  from  its  con- 
nections, a  double  ligature  was  passed  under  it,  and  then 
separated,  so  as  to  form  two  distinct  ligatures,  with  a  portion 
of  the  vessel  lying  between  them :  two  additional  ligatures 
were  applied  at  certain  distances  from  the  two  former,  making 
four  in  all.  This  was  done  with  a  view  to  secure  adhesion, 
by  compressing  a  larger  extent  of  the  vessel.  On  the  fifteenth 
day,  some  of  the  ligatures  came  away.  Soon  after,  the  patient 
left  the  hospital  with  some  open  abscesses ;  and  six  months 
after,  more  of  the  ligatures  came  away,  and  the  patient  per- 
fectly recovered.     In  an  earlier  part  of  the  same  year,  Des- 


OPERATIONS  ON  THE  FEMORAL  ARTERY.      337 

sault  had  tied  the  popliteal  artery  for  popliteal  aneurism ;  but 
Hunter's  merit  consisted  in  having  tied  the  artery  at  a  dis- 
tance from  the  diseased  part.  It  is  scarcely  necessary  to 
inform  the  advanced  student  that  the  number  of  ligatures 
employed  by  Mr.  Hunter,  and  the  extent  of  the  artery  de- 
tached from  its  connections,  were  calculated  to  produce  most 
dangerous  consequences,  such  as  abscesses  and  secondary 
hemorrhage.  In  his  second  operation  he  committed  another 
error  in  dressing  the  wound  from  the  bottom;  but  it  is  proper 
to  add  that  he  gradually  corrected  these  errors,  and  in  his 
subsequent  practice  used  only  a  single  ligature,  and  en- 
deavored to  unite  the  wound  as  quickly  as  possible. 

Ligature  of  the  Femoral  Artery  imnfiediately  helow  Pou- 
part's  ligament. — Professor  Porter  proposed  and  performed 
the  operation  of  tying,  the  femoral  artery  for  aneurism  of 
this  vessel,  by  making  a  transverse  incision  through  the  in- 
teguments, and  so  reaching  the  artery  whilst  enclosed  within 
the  funnel,  and  of  course  before  it  had  given  origin  to  the 
profunda:  the  operation  was  successful.  Mr.  Butcher  per- 
formed Mr.  Porter's  operation  in  Mercer's  Hospital,  in  the 
case  of  a  wound  of  the  profunda  femoral  artery.  The  patient 
sunk  from  loss  of  blood  in  twenty-four  hours  after  the  in- 
fliction of  the  wound.*  Mr.  George  Porter  and  Mr.  Smyly 
have  also  tied  the  artery  according  to  Mr.  Porter's  method, 
in  the  Meath  Hospital,  for  aneurism,  with  complete  success. 
The  femoral  artery  has  been  tied  before  the  giving  off  of  the 
profunda  for  hemorrhage  after  amputation  of  the  thigh. 

Ligature  of  the  Femoral  Artery  in  the  middle  of  the  thigh. — 
In  this  situation  the  artery  is  covered  by  the  sartorius  muscle, 
and  much  discussion  has  arisen  whether  it  be  preferable  to 
cut  down  on  its  internal  margin  and  evert  it,  or  on  its  outer 


Dub.  Quar.  Med.  Jour.,  vol.  xviii.  p.  2. 
29 


338  OPERATIONS   ON    THE   FEMORAL   ARTERY. 

margin,  and  then  draw  it  inwards.*  Both  modes  have  their 
advocates:  Mr.  Hunter,  whose  operation  has  already  been 
described,  adopted  the  former  plan,  and  the  advocates  for  it 
affirm  that  it  can  be  more  easily  done,  and  that  a  depending 
opening  is  thus  gained  for  the  exit  of  matter.  On  the  other 
hand,  Mr.  Hutchinson,  who  has  written  a  letter  to  recommend 
the  latter  plan,  objects  to  the  internal  incision, — that  the 
artery  is  not  easily  found  in  this  way,  and  that  the  saphena 
vein  and  trunks  of  the  lymphatics  are  greatly  endangered. 
The  truth  is,  that  if  we  operate  on  the  termination  of  the 
femoral  artery,  as  Hunter  did,  we  will  find  it  easier  to  expose 
this  vessel  by  cutting  on  the  outer  edge  of  the  muscle;  but 
if  we  operate  immediately  below  Scarpa's  angle,  which  is  a 
simpler  and  better  operation,  we  must  of  necessity  cut  on  the 
internal  edge  of  the  sartorius,  unless  we  choose  to  have  a 
tedious  and  difficult  operation  and  a  valvular  opening  in  order 
to  reach  the  artery.  By  not  attending  to  this  distinction, 
many  useless  discussions  have  arisen.  In  this  country  sur- 
geons usually  operate  in  Scarpa's  space ;  but  in  France,  we  are 
informed  by  Velpeau,  that  the  operation  below  this  point,  that 
is,  in  the  middle  third  of  the  thigh,  is  usually  preferred. 

If  the  artery  be  tied  just  before  it  reaches  the  tendon  of 
the  adductor  niagnus  muscle  (an  operation  which  is  not 
recommended),  in  order  to  avoid  the  saphena  vein  and  come 
readily  on  the  artery,  the  incision  should  be  made  over  the 
external  or  anterior  margin  of  the  sartorius.  If  care  be  not 
taken  to  divide  the  strong  fascia  that  lies  beneath  this  muscle, 
it  will  be  almost  impossible  to  find  the  artery.  The  operator 
must  also  take  care  not  to  mistake  the  anastomotic  for  the 
femoral  artery :  this  error  has  been  committed.  Lastly,  he 
should  remember  how  closely  the  artery  and  vein  are  con- 
nected in  this  situation ;  and,  as  the  vein  projects  a  little  to 


*  Dessault  proposes  cutting  this   muscle  across,  which  can  never  be 
necessary  ;  though  we  are  informed  it  produces  no  permanent  injury. 


OPERATIONS  ON  THE  FEMORAL  ARTERY.     389 

the  outside  of  the  artery,  the  needle  should  be  passed  from" 
without  inwards,  taking  care  not  to  include  the  saphenous 
or  the  genicular  nerves. 

If  the  artery  be  tied  higher  up  in  the  middle  third  of  the 
thigh,  our  incision  should  be  made  over  the  internal  margin 
of  the  sartorius  muscle :  the  fascia,  which  is  much  weaker  in 
this  situation,  must  be  next  divided,  and  the  artery  will  then 
be  exposed.  The  nerves  are  to  be  carefully  avoided,  and  the 
needle  passed  from  within  outwards. 

Ligature  of  the  Femoral  Artery  in  Scarpa's  Space. — The 
patient  is  to  be  placed  on  his  back,  on  a  table,  and  the  thigh 
rotated  slightly  outwards,  so  as  to  make  the  incision  look 
directly  upwards.  The  line  of  the  artery  is  to  be  distin- 
guished by  feeling  its  pulsation,  which  will  become  indistinct 
or  imperceptible,  inferiorly,  where  the  sartorius  begins  to 
overlap  it.  In  the  course  of  this  line,  the  first  incision  should 
be  made  through  the  integuments,  commencing  about  two 
inches  beneath  Poupart's  ligament,  and  extending  from  about 
two  inches  and  a  half  to  three  inches  in  length.  This  inci- 
sion will  lie  on  the  outside  of  the  saphena  vein.  The  super- 
ficial fascia  should  be  next  cautiously  divided.  Any  lym- 
phatic gland,  or  large  cutaneous  veins,  that  present  themselves, 
should  be  carefully  avoided.  A  portion  of  the  fascia  lata 
should  then  be  raised  in  the  forceps,  and  divided  horizontally ; 
after  which  a  director  should  be  introduced  into  the  opening 
in  the  fascia,  with  the  view  of  enlarging  it  to  the  extent  of  an 
inch.  The  sheath  of  the  vessel  is  now  to  be  divided  in  the 
same  cautious  way,  when  the  artery  will  be  brought  into  view. 
The  femoral  vein  lies  immediately  behind  the  artery ;  there- 
fore a  blunt  instrument,  such  as  an  eye-probe,  must  be  em- 
ployed, with  great  caution,  to  separate  them.  The  needle  is 
then  to  be  passed  round  the  artery,  from  within  outwards ; 
keeping  it  close  to  the  artery,  in  order  to  avoid  the  vein  and 
some  small  branches  of  the  crural  nerve,  which  usually  lie 


340    STATE  OP  COLLATERAL  VESSELS  AFTER  OPERATION. 

to  its  outside.  In  some  cases  a  nerve  will  lie  directly  over 
the  artery ; — it  should  be  carefully  drawn  out  of  the  way. 
Should  the  femoral  vein  be  unfortunately  wounded,  there  will 
probably  be  no  notice  given  of  the  occurrence  till  the  needle 
is  withdrawn,  and  then  a  gush  of  black  blood  will  announce 
the  accident.  This  is  certainly  an  alarming  occurrence ;  but 
we  have  known  it  to  happen,  and  the  patient  notwithstand- 
ing to  recover,  without  suffering  any  inconvenience  whatever 
from  it. 

State  of  the  circulation  and  vessels  after  the  operation. — 
When  the  femoral  artery  is  tied  above  the  origin  of  the  pro- 
funda, the  circulation  in  the  limb  is  carried  on  in  the  same 
manner  as  if  the  external  iliac  were  tied. 

When  the  femoral  artery  is  tied  beneath  the  origin  of  the 
profunda,  we  find  the  circulation  maintained  by  the  latter 
vessel,  the  circumflex  branches  of  which  freely  anastomose 
with  the  anastomotic  and  inferior  muscular  branches  of  the 
femoral,  and  with  the  articular  branches  of  the  popliteal. 
If  this  operation  have  been  performed  for  popliteal  aneu- 
rism, the  femoral  artery  afterwards  becomes  impervious  as 
far  up  as  the  origin  of  the  profunda;*  and  the  portion  of 
it  between  the  ligature  and  aneurismal  tumor  may  either  be 
obliterated  throughout,-}-  or  pervious  throughout;  or  it  may 
be  partly  pervious,  being  interrupted  at  different  parts  of  its 
course  by  points  of  obliteration.  If  the  femoral  artery  be 
tied  below  the  profunda,  independently  of  aneurism,  the 
obliteration  on  either  side  of  the  ligature  will  extend  to  the 
next  considerable  branch. J 

*■  In  some  of  the  cases,  however,  in  which  the  artery  has  heen  tied  low 
down,  the  impervious  state  may  not  extend  to  the  origin  of  the  profunda, 
but  only  to  the  origin  of  the  muscular  branches. 

t  Sir  A.  Cooper  in  Med.  Ch.  Trans.,  vol.  i. 

}  Hodgson  on  the  Arteries.     Todd's  Cyclop.,  art.  Femoral  Artery. 


COMPRESSION   ON   THE   FEMORAL  ARTERY.  341 

Treatment  of  Popliteal  Aneurism  hy  Compression  on  the 
FeTnornl  Artery. — The  treatment  of  aneurism  by  compression 
upon  the  artery  leading  to  the  tumor,  may  be  considered  as 
one  of  the  greatest  achievements  in  modern  surgery.  In 
this  city  it  has  almost  entirely  superseded  the  operation  of 
tying  the  femoral  artery.  It  accomplishes  without  danger 
what  Hunter's  operation  effected  with  the  risk  of  human  life. 
It  is  obvious,  however,  that  it  is  not  applicable  to  every  form 
of  this  disease  ]  nor  can  it  be  exercised  on  many  of  the  arte- 
ries of  the  body.  Mr.  Todd  had  recourse  to  this  method  in 
June,  1820,  for  the  cure  of  a  popliteal  aneurism  in  the  right 
ham.  He  observes,  "  The  disease  in  this  case  was  so  recent 
that  it  was  resolved  to  watch  its  progress  for  some  time  before 
an  operation  should  be  decided  on.  The  patient  was  accord- 
ingly directed  to  remain  in  a  horizontal  posture ;  he  was  put 
upon  low  regimen  and  occasionally  blooded  and  purged.  The 
tumor  was  so  much  under  the  control  of  pressure  on  the 
inguinal  portion  of  the  artery,  that  I  was  not  altogether 
without  hope  that  by  diminishing  the  current  of  blood  in  the 
trunk  of  the  artery,  so  as  to  favor  the  coagulation  of  the 
contents  of  the  sac,  a  cure  without  operation  might  be  effected : 
at  all  events,  it  was  obvious  that  by  giving  time  to  the  col- 
lateral arteries  to  be  dilated,  the  success  of  the  operation  would 
be  rendered  less  uncertain."  The  instrument  employed  by 
Mr.  Todd  resembled  a  common  truss  for  femoral  hernia,  but 
the  "  spring  was  much  stronger,  and  the  pad  longer,  of  a 
more  oval  form  and  more  firmly  stuffed  than  in  the  truss.'' 
After  a  trial,  however,  of  several  weeks,  the  patient  "  could 
not  be  persuaded  that  the  plan  adopted  was  productive  of  bene- 
fit; during  this  period  the  tumor  had  obviously  diminished, 
and  its  contents  had  acquired  a  firm  consistence,  but  the 
patient  complained  that  the  instrument  gave  him  much  pain, 
and  that  his  health  and  spirits  had  suffered  materially  from 
confinement,  rigid  abstinence,  &c.;  the  operation  was  accord- 
ingly agreed  to,  and  I  performed  it  on  the  1st  of  September, 

29* 


342     COMPRESSION  ON  THE  FEMORAL  ARTERY. 

being  two  months  after  his  admission  into  the  hospital."  In 
July  of  the  same  year,  Mr.  Todd  had  another  opportunity  of 
trying  this  mode  of  compression  on  the  femoral  artery  for  the 
cure  of  popliteal  aneurism  in  the  left  ham ;  in  a  few  weeks  no 
alteration  could  be  observed  in  the  tumor ;  the  man  became 
impatient  and  refused  to  submit  to  the  treatment,  so  that  in 
this  case  also  the  operation  was  finally  performed.*  On  the 
27th  of  August,  1824,  Mr.  M'Coy  applied  compression  to  the 
femoral  artery  for  the  cure  of  aneurism  of  that  vessel  occur- 
ring in  a  stump  after  amputation  for  a  diflfused  popliteal  aneu- 
rism. The  patient  perfectly  recovered,  and  lived  for  several 
years  afterwards.f  In  the  year  1825,  compression  of  the 
femoral  artery  was  successfully  employed  by  Mr.  Todd  for  the 
cure  of  a  popliteal  aneurism. J  In  the  year  1842,  this  mode 
of  treatment  was  successfully  revived  in  this  city  by  Dr, 
Hutton :  the  patient,  Michael  Duncan,  aet.  30,  a  laborer, 
was  admitted  into  the  Richmond  Hospital  on  the  3d  of  Octo- 
ber, in  the  same  year,  laboring  under  a  popliteal  aneurism 
in  the  right  ham.  Dr.  Hutton  states,  that  "  on  November  1st, 
the  patient  being  still  reluctant  to  undergo  the  operation,  I 
resolved  to  try  compression  of  the  femoral  artery,  and  I  enter- 
tained some  hope  of  succeeding,  being  informed  by  Mr. 
Adams  that  the  late  Mr.  Todd  had  succeeded  in  a  similar 
case,  of  which  no  account  has  been  published.  Having  at 
hand  an  instrument  constructed  for  the  suppression  of 
secondary  hemorrhage  after  ligature  of  the  femoral  artery, 
I  applied  it  in  this  case.  It  was  so  contrived  as  to  admit 
of  pressure  being  made  by  a  screw  and  pad  upon  the  course 
of  the  femoral  artery,  and  the  counter-pressure  upon  the 
opposite  surface  of  the  limb,  without  interfering  with  the 
collateral  circulation.     In  the  first  instance  the  compression 

*  Dublin  Hospital  Reports,  vol.  iii.  p.  91,  &c. 

t  Medical  Press,  April  26,  1843  j  and  Mr.  Adams  in  Dub.  Quar.  Jour., 
Aug.  1846. 
i  Dub.  Quar.  Jour.,  Aug.  1846. 


COMPRESSION   ON   THE   FEMORAL   ARTERY.  343 

was  made  upon  the  femoral  artery  in  the  middle  third  of 
the  thigh,  and,  although  it  was  effectual  in  compressing 
this  vessel,  it  produced  so  much  uneasiness  that  it  could 
not  be  sustained,  and  after  a  few  applications  the  appa- 
ratus was  removed  and  adapted  to  the  upper  part  of  the 
limb.  On  November  12th,  the  apparatus  was  applied  on  the 
femoral  artery  in  this  case,  immediately  below  Poupart's  liga- 
ment, and  the  pressure  was  maintained  for  more  than  four 
hours.  From  this  date  to  December  1st,  the  instrument  was 
occasionally  applied  for  a  given  number  of  hours  at  each  time, 
and  on  this  day  the  tumor  was  quite  solid,  much  diminished 
in  size,  and  altogether  free  from  pulsation.  On  the  27th  of 
December  the  patient  was  discharged  at  his  own  request." 
Dr.  Button  further  reports  : — "  In  six  weeks  he  visited  the 
hospital  at  my  request :  the  tumor  was  about  the  size  of  a 
nutmeg,  and  solid.     He  had  been  at  his  usual  employment." 

^^  Remarks. — Since  this  case  occurred,  Dr.  Cusack  has 
treated  with  success,  by  similar  means,  a  case  of  popliteal 
aneurism  in  Dr.  Stevens's  Hospital,  and  Dr.  Bellingham  another 
in  St.  Vincent's  Hospital.  It  would  appear  that  this  plan  of 
treatment  has  been  too  hastily  abandoned  by  the  profession, 
probably  from  the  compression  employed  being  so  excessive 
as  to  render  it  quite  insupportable  to  the  patient.  The  least 
possible  pressure,  which  may  be  sufficient  to  close  the  vessel, 
should  be  used,  and  when  this  cannot  be  sustained,  it  will 
prove  of  use  to  partially  compress  the  artery  so  as  to  lessen 
the  impulse  of  the  circulation."* 

At  a  meeting  of  the  Surgical  Society,  held  on  the  22d  of 
April,  1843,  Dr.  Bellingham  reported  "  two  cases  of  popliteal 
aneurism  recently  cured  by  pressure  upon  the  femoral  artery." 
The  first  case,  that  of  Michael  Duncan  as  already  stated,  was 
treated  by  Dr.  Hutton,  the  second  by  Dr.  Bellingham  him- 
self", and  as  Dr.  Hutton  was  prevented  from  attending,  he 

*  Dublin  Medical  Journal,  vol.  xxiii.  p.  364,  «5;c. 


344  COMPRESSION    ON   THE   FEMORAL   ARTERY. 

furnished  the  notes  of  his  own  case  to  Dr.  Bellingham,  who 
read  them  to  the  society.  This  report  of  Dr.  Hutton's  case 
we  need  not  quote,  as  the  student  is  already  in  possession  of 
the  principal  facts  connected  with  it.  In  his  communication, 
however,  Dr.  Hutton  observes,  "  As  the  apparatus  made  use 
of  by  Dr.  Bellingham  was  far  superior  to  that  which  I  had 
at  my  command,  and  as  he  will  publish  a  description  of  it,  it 
is  unnecessary  for  me  to  refer  to  this  part  of  the  subject." 

In  the  same  communication  Dr.  Bellingham  related  the 
following  particulars  of  his  own  case : — 

"  Patient  a  servant,  set.  32,  healthy,  admitted  into  St.  Vin- 
cent's Hospital,  under  Dr.  Bellingham,  March  25th,  1843, 
laboring  under  popliteal  aneurism  upon  the  right  side. 
Tumor  noticed  three  months  previously;  patient's  attention 
attracted  to  it  by  a  feeling  of  weakness  in  the  limb;  no  cause 
assigned  for  it.  The  aneurisni,  seated  high  in  the  popliteal 
space,  measures  about  three  inches  transversely,  and  a  little 
more  from  above  downwards;  the  sac  can  be  completely 
emptied  by  pressure  upon  the  artery  in  the  thigh.  Compres- 
sion commenced  April  3d;  the  pressure  applied  upon  the 
artery  as  it  passes  over  the  ramus  of  the  pubis;  discontinued 
on  the  following  day;  reapplied  April  6th;  pulsation  ceased  on 
the  following  day,  at  which  period  the  tumor  is  reported  to 
have  been  about  the  size  of  a  small  orange,  solid  and  hard. 
Instruments  removed  April  11th.  Patient  discharged  a  month 
afterwards;  the  tumor  being  then  very  small;  he  had  perfect 
use  of  the  limb.  Duration  of  compression,  two  days."  The 
report  of  the  proceedings  of  this  meeting,  published  in  the 
Medical  Press  of  May  3d,  1843,  are  accompanied  with  an 
engraving  of  the  apparatus  employed  by  Dr.  Bellingham, 
and  to  which  Dr.  Hutton  refers  in  his  communication.  In 
the  Medical  Press  of  May  15th,  1849,  Dr.  Hutton  mentions 
a  case  of  popliteal  aneurism,  in  which  he  compressed  the 
femoral  artery  with  Dr.  Carte's  apparatus.  The  compression 
was  employed  for  only  seven  hours  and  a  half  successively; 


BRANCHES   OF   THE   FEMORAL  ARTERY.  345 

after  this,  the  tumor  became  solid,  and  absorption  soon  com- 
menced. 

Many  other  cases  have  also  been  recently  treated  by  several 
surgeons  in  this  city  as  well  as  in  England,  with  the  most 
complete  success ;  these  cases  appeared  in  the  periodicals  of 
the  day,  and  have  since  been  published  in  a  collective  form 
up  to  the  year  1847,  by  Dr.  Bellingham  of  St.  Vincent's 
Hospital.  Since  that  date  the  subject  has  been  continued  up 
to  the  year  1851  by  Mr.  Tufnell,  one  of  the  surgeons  to  the 
City  of  Dublin  Hospital,  in  his  "Practical  Kemarks  on  the 
Treatment  of  Aneurism  by  Compression." 

The  femoral  artery  gives  off  the  following  branches  : — 

Superficial  Epigastric.  Profunda  Femoris. 

External  Pudic.  Muscular. 

Superficial  Circumflexa  Ilii.     Anastomotica  Magna. 

The  Superficial  Epigastric  Artery  arises  a  little  below  Pou- 
part's  ligament,  pierces  the  fascia  lata,  and  ascends  towards 
the  umbilicus  in  front  of  Poupart's  ligament.  It  supplies  the 
glands  of  the  thigh,  and  the  fascia  and  integuments  of  the 
abdomen,  and  anastomoses  with  the  internal  epigastric  and 
mammary  arteries. 

The  External  Pudic  Arteries  are  two  in  number,  a  super- 
ficial and  a  deep :  the  superficial  comes  off  a  little  below  Pou- 
part's ligament,  croses  superficial  to  the  fascia  lata,  to  reach 
the  scrotum  in  the  male,  or  labium  in  the  fomale,  in  which 
parts,  and  in  the  abdominal  muscles,  it  is  lost;  the  deep  pudic 
branch  crosses  behind  the  fascia  lata,  and  below  the  former 
branch,  and  supplies  the  scrotum  in  the  male,  and  the  labium 
in  the  female,  and  terminates  in  the  perineum.  These 
branches  anastomose  with  each  other,  and  the  superficial 
anastomoses  with  the  superficial  epigastric. 

The  Superficial  Circumflexa  Ilii,  smaller  than  the  pre- 
ceding, follows  the  course  of  Poupart's  ligament  beneath  the 
integuments,  and  at  the  anterior  superior  spine  of  the  ilium 


846  PROFUNDA   FEMORAL   ARTERY. 

terminates  in  anastomosing  with  the  deep  circumflexa  ilii,  the 
ilio-lumbar,  glut83al,  and  external  circumflexa  femoris  arteries. 

The  profunda  is  the  next  branch  given  oiF  from  the  femoral ; 
but  it  will  be  more  convenient  to  examine  the  muscular  and 
the  anastomotic  arteries  first. 

The  Muscular  branches  are  small  and  irregular :  they  arise 
from  the  femoral  in  its  course  down  the  thigh,  and  are  dis- 
tributed to  the  muscles  of  the  thigh  in  the  neighborhood  of 
the  femoral  artery,  chiefly  to  the  sartorius  and  vastus  internus. 

The  Anastomotica  Magna  Artery  comes  ofi"  immediately 
before  the  femoral  artery  passes  between  the  tendons  of  the 
adductor  magnus  and  vastus  internus  muscles  :  together  with 
the  internal  saphenous  nerve,  it  pierces  the  anterior  wall  of 
the  Hunterian  canal,  and  divides  into  three  branches;  one  of 
these  crosses  transversely  outwards  through  the  fibres  of  the 
vastus  internus  muscle;  another  runs  downwards  and  out- 
wards in  the  course  of  the  fibres  of  the  same  muscle;  and  a 
third  descends  with  the  saphenous  nerve  to  the  inside  of  the 
knee-joint,  where  it  is  distributed.  These  three  branches 
sometimes  come  ofi^  separately  from  the  femoral. 

The  Profunda  Femoral  Artery. — This  artery  arises 
from  the  posterior  and  external  part  of  the  femoral,  at  about 
an  inch  and  a  half  to  two  inches  below  Poupart's  ligament; 
in  some  rare  cases  it  arises  much  lower  down.  It  proceeds 
obliquely,  at  first  downwards  and  outwards,  over  the  tendon 
of  the  psoas  and  the  upper  extremity  of  the  cruraeus  muscle; 
it  then  turns  inwards  over  the  vastus  internus  muscle,  be- 
comes related  externally  to  the  anterior  crural  nerve  at  its 
division,  and  descends  between  the  adductor  longus  and 
magnus,  the  former  muscle  separating  it  from  the  femoral 
artery.  From  ^ts  origin  till  it  disappears  behind  its  parent 
trunk,  the  artery  forms  a  curve,  the  convexity  of  which  is 
directed  outwards :  after  its  origin,  it  is  situated  on  the  out- 
side of  the  femoral  artery,  afterwards  it  turns  underneath  it 


EXTERNAL   CIRCUMFLEX   ARTERY.  347 

and  becomes  separated  from  it  by  the  profunda  and  femoral 
veins,  together  with  a  quantity  of  areolar  tissue  containing 
several  small  vessels;  and  as  it  descends  still  lower,  its  termi- 
nating portion  lies  behind  the  adductor  longus  tendon.  At 
first,  therefore,  the  artery  is  comparatively  superficial,  but  as  it 
continues  its  course  it  becomes  more  deeply  seated  in  the  thigh. 
The  profunda  artery  gives  off  the  following  branches : — 

External  Circumflex.  Internal  Circumflex. 

Perforating. 

The  External  Circumflex  Artery  arises  from  the  external 
side  of  the  profunda,  where  the  latter  is  forming  its  curvature 
in  order  to  descend  inwards :  from  this  origin  it  runs  almost 
transversely  outwards  behind  the  sartorius  and  rectus  muscles, 
and  through  the  midst  of  the  fasciculus  of  branches  descend- 
ing from  the  anterior  crural  nerve.  It  terminates  in  three 
branches:  an  ascending,  transverse,  and  descending.  The 
ascending  branch,  considerably  the  smallest,  runs  upwards 
and  outwards  behind  the  tensor  vaginae  femoris,  in  the  in- 
terval between  the  iliacus  internus  and  glutaeus  medius  muscles, 
till  it  reaches  the  anterior  superior  spine  of  the  ilium,  where 
it  terminates  in  anastomosing  with  the  superficial  and  deep 
circumflexa  ilii  arteries,  and  with  the  glutasal  and  ilio-lumbar. 
The  transverse  hranchj  larger  than  the  preceding,  runs  out- 
wards, in  front  of  the  superior  extremity  of  the  shaft  of  the 
femur,  and  then  curves  round  to  its  posterior  surface :  in  this 
course  it  passes  through  the  superior  fibres  of  the  vastus  ex- 
ternus,  and  then  pierces  the  insertion  of  the  glutaeus  maxi- 
mus.  On  raising  the  latter  muscle,  the  termination  of  this 
branch  is  seen :  it  supplies  the  adductor  muscles,  the  vastus 
externus,  and  the  capsule  of  the  hip-joint.  The  descending 
branch  (or  rather  set  of  branches,  as  there  are  usually  two  and 
frequently  more)  is  much  the  largest;  it  runs  downwards  and 
outwards,  first  between  the  rectus  muscle  and  cruraeus,  and 
then  between  the  f  astus  externus  and  cruraeus :  it  sends  many 


348 


INTERNAL   CIRCUMFLEX   ARTERY. 


branches  to  these  muscles,  and  terminates  near  the  patella  in 
inosculation  with  the  anastomotic  and  external  articular 
arteries.  When  there  is  but  one  descending  branch,  it  goes 
to  the  vastus  externus.  This  branch  is  sometimes  greatly  en- 
larged in  cases  of  popliteal  aneurism;  and  in  amputations  of 
the  thigh  it  frequently  requires  the  application  of  a  ligature. 

Fig.  61. — Represents  the  Anastomosis  between  the  Obturator  and  Internal  Circumflex 
Arteries. 


1,  1,  Psoas  Magnus  Muscle.  2,  2,  lliacus  Internus  Muscle.  3.  Glutaeus  Medius  Muscle.  4,  Tensor 
Vaginae  Femoris  Muscle.  5,  Origin  of  Sartorius  Muscle.  6,  Portion  of  Rectus  Femoris  Muscle.  7, 
Vastus  Externus.  8,  Crurseus.  9,  Origin  of  the  Pectineus  Muscle.  10,  Origin  of  Adductor  Longus. 
11,  Insertion  of  preceding  Muscle  into  the  middle  third  of  the  Linea  Aspera.  12,  Obturator  Externus 
Muscle.  13,  Adductor  Magnus  Muscle.  14,  Adductor  Brevis  Muscle.  15,  Urinary  Bladder.  Ifi,  Divi- 
sion of  Abdominal  Aorta.  17,  Middle  Sacral  Artery.  18.  Left  Common  Iliac  Artery.  19,  Internal 
Iliac  Artery.  20,  Obturator  Artery.  21,  Capsular  Ligament  of  hip  joint.  22.  Muscular  twig  to  the 
Adductors.  23,  External  Iliac  Artery.  24,  The  Internal  Circuniliexa  Illi  Artery.  25,  Epigastric 
Artery,  cut.  26,  E.\ternal  Circumtlexa  Ilii  Artery.  27,  Superficial  Epigastric  Artery,  cut.  28, 
Femoral  Artery,  cut.  29,  Profunda  Artery.  30,  Descending  branches  of  External  Circumflex  Artery. 
31,  Internal  Circumflex  Artery.    32,  Anastomosis  between  Internal  Circumflex  and  Obturator  Arteries. 

The  Internal  Circumflex  Artery^  usually  larger  than  the 
external,  arises  from  the  posterior  and  internal  part  of  the 
profunda.  It  jBrst  sinks,  from  before  backwards,  between  the 
pectineus  and  the  tendon  of  the  psoas  and  iliacus;  next  be- 
tween the  obturator  externus  muscle  abovef  and  the  superior 


INTERNAL   CIRCUMFLEX    ARTERY.  349 

edge  of  the  adductor  brevis  below;  and,  lastly,  between  the 
lower  margin  of  the  quadratus  femoris  and  the  upper  fibres 
of  the  adductor  magnus.  In  this  course  it  winds  round  the 
inside  of  the  neck  of  the  femur  and  capsule  of  the  hip-joint: 
its  termination  may  be  seen  by  raising  the  glutaeus  maximus. 
The  course  of  the  artery  between  these  layers  of  muscles  and 
adjacent  parts  has  been  thus  described  by  Dr.  Harrison: — "It 
is  surrounded  by  a  quantity  of  loose  cellular  membrane,  and 
is  situated  in  a  sort  of  cavity  of  a  triangular  figure,  bounded 
externally  by  the  capsular  ligament,  by  the  neck  of  the  femur, 
and  by  the  psoas  and  iliac  muscles  and  tendon ;  superiorly  by 
the  obturator  externus;  and  internally  by  the  adductor  muscles : 
this  space  is  covered  anteriorly  by  the  pectineus,  and  partly 
closed  posteriorly  by  the  adductor  magnus  and  quadratus 
femoris,  between  which  muscles  there  is  a  narrow  fissure, 
through  which  pass  the  terminating  branches  of  this  artery." 
The  branches  of  the  internal  circumflex  may  be  classed  into 
the  internal,  external,  ascending,  and  terminating.  The 
internal  branches  are  distributed  to  the  adductor  muscles,  and 
sometimes  supply  the  place  of  the  superficial  pudic  arteries. 
The  external  branch*  is  small;  it  passes  through  the  notch 
in  the  internal  margin  of  the  acetabulum  and  beneath  the 
transverse  ligament,  and  is  then  conducted  by  the  ligamentum 
teres  to  the  head  of  the  femur,  which  it  supplies.  The  ascend- 
ing branches  supply  the  pectineus  and  origin  of  the  adductor 
longus :  on  dividing  the  pectineus,  we  find  them  freely  inoscu- 
lating with  the  branches  of  the  obturator  artery;  and  still 
deeper  there  is  a  trochanteric  branch,  which  ascends  in  front 
of  the  quadratus  femoris  muscle,  to  arrive  at  the  digital  fossa 
of  the  great  trochanter :  it  supplies  the  muscles  inserted  in 

*  In  complete  fracture  of  the  neck  of  the  femur,  within  the  capsular 
ligament,  this  and  a  similar  branch  of  the  obturator  are  the  only  direct 
sources  from  which  the  head  of  the  bone  can  receive  blood ;  and  this  is 
one  of  the  reasons  assigned  by  Sir  A.  Cooper  why  osseous  union  does  not 
occur  in  those  cases. 

30 


350  PERFORATING   ARTERIES   OP   THE   THIGH. 

tins  situation,  and  inosculates  with  the  sciatic,  glutaeal,  and 
external  circumflex  arteries.  On  placing  the  subject  on  its 
face  and  raising  the  glutaeus  maximus  muscle,  we  see  the 
termination  of  the  internal  circumflex  artery  running  inwards 
and  backwards  along  the  lower  margin  of  the  quadratus  femoris 
muscle,  through  a  space  formed  between  this  muscle  ulteriorly ^ 
the  upper  part  of  the  adductor  magnus  inferiorhj,  and  the 
root  of  the  trochanter  minor  externally.  Here  it  supplies  the 
origins  of  the  hamstring  muscles,  the  adductor  magnus,  and 
the  sciatic  nerve,  and  anastomoses  freely  with  the  sciatic  and 
glutaeal  arteries. 

On  one  occasion  M.  Koux  cut  down  on  this  vessel,  and  tied 
it;  but  such  an  operation  will  be  seldom  necessary. 

The  Perforating  Arteries  are  three  in  number;  the  termi- 
nation of  the  profunda  is  often  described  as  a  fourth.  The 
fij'st  arises  a  little  below  the  lesser  trochanter ;  it  passes  back- 
wards beneath  the  lower  edge  of  the  pectin eus  muscle,  and 
above  the  adductor  brevis,  and  pierces  the  aponeurosis  of  the 
adductor  magnus :  sometimes  it  passes  through  the  adductor 
brevis  muscle.  It  then  divides  into  two  principal  branches, 
one  of  which  ascends  in  the  substance  of  the  glutaeus  maxi- 
mus, while  the  other  descends  in  the  long  head  of  the  biceps, 
and  also  supplies  the  vastus  externus,  semi-membranosus,  and 
semi-tendinosus  muscles.  This  artery  anastomoses  with  the 
glutaeal,  sciatic,  circumflex,  and  inferior  perforating  arteries. 
The  second  is  the  largest  of  the  perforating  arteries :  it  arises 
a  little  below  the  preceding,  and  pierces  the  tendons  of  the 
adductor  brevis  and  magnus,  sometimes  of  the  great  adductor 
only ;  it  then  divides  into  several  branches  which  supply  the 
glutaeal  and  hamstring  muscles,  and  communicate  with  the 
other  perforating  arteries.  It  also  gives  off  the  nutritious 
artery  of  the  femur,  or  artery  of  the  medullary  membrane : 
this  small  vessel  enters  a  foramen  in  the  linea  aspera  usually 
near  the  centre  of  the  bone ;  from  this  it  runs  along  a  canal 
which  passes  obliquely  through  the  compact  tissue  of  the  bone 


THE   POPLITEAL   SPACE.  351 

towards  its  upper  extremity,  and  ramifies  on  the  medullary 
membrane.  The  third  is  the  smallest  of  the  three ;  it  passes 
backward  below  the  adductor  brevis,  then  pierces  the  aponeu- 
rosis of  the  adductor  magnus,  and  its  branches  are  distributed 
in  the  same  manner  as  the  two  other  perforating  arteries. 

The  Terminating  branch  appears  as  the  continuation  of  the 
profunda  itself,  though  greatly  diminished  in  size:  it  lies 
upon  a  plane  posterior  to  the  adductor  longus  muscle,  perfo- 
rates the  adductor  magnus,  supplies  the  hamstring  muscles 
and  inosculates  with  the  perforating  arteries,  and  the  articular 
arteries  about  the  knee.  This  vessel  is  sometimes  called  the 
fourth  perforating  artery. 

After  the  femoral  artery  has  given  off  its  anastomotic 
branch,  it  descends  obliquely  backwards  through  an  oblique 
slit  or  opening  between  the  adductor  magnus  muscle  and  the 
vastus  internus,  and,  having  arrived  in  the  popliteal  space, 
becomes  the  popliteal  artery.  The  opening  is  bounded  on  the 
outside  by  the  vastus  internus;  on  the  inside  by  the  adductor 
magnus ;  inferiorly  by  the  union  of  the  tendon  of  this  last 
muscle  with  the  tendon  of  the  vastus  internus,  and  superiorli/ 
by  the  union  of  the  tendons  of  the  adductors  longus  and 
magnus.  Its  circumference  is  entirely  tendinous,  in  order  to 
provide  against  any  obstruction  to  the  circulation  which  would 
arise  from  the  pressure  of  the  muscular  fibres  upon  the  artery 
and  vein  in  their  passage  through  the  opening. 

THE   POPLITEAL    SPACE. 

This  name  is  given  to  the  hollow  in  the  posterior  region  of 
the  knee-joint.  It  occupies  about  the  inferior  third  of  the 
posterior  part  of  the  thigh,  and  the  superior  fifth  of  the  back 
part  of  the  leg.  On  raising  the  integuments,  we  bring  into 
view  a  layer  of  adipose  and  areolar  tissue :  in  this  layer  we 
notice  the  terminating  filaments  of  the  posterior  cutaneous 
nerve  of  the  thigh,  which  is  a  branch  of  the  sacral  plexus; 
and  sometimes  we  find  the  posterior  saphena  vein :  when  this 


352 


THE    POPLITEAL   SPACE. 


Fig.  62.— Surgical 
62  A. 


of  the  Popliteal  Space  and  posterior  part  of  Leg. 
62  B. 


THE   POPLITEAL   SPACE.  353 

vein  is  so  superficial,  it  passes  through  a  small  opening  in  the 
popliteal  fascia  and  joins  the  popliteal  vein:  we  find  also  in 
this  stage  of  the  dissection  some  minute  veins  and  lymphatic 
vessels  which  pass  from  the  integuments  through  the  popliteal 
fascia  into  the  interior  of  the  popliteal  space.  We  may  next 
examine  the  popliteal  fascia,  the  fibres  of  which  run  trans- 
versely in  the  upper  part  of  the  popliteal  space,  and  obliquely 
in  its  lower  part.  The  fascia  is  of  considerable  strength,  and 
is  attached  to  the  hamstring  muscles  on  either  side,  forming  a 
special  sheath  for  each :  it  is  also  connected  along  the  sides 
of  the  space,  internally  by  a  deep  process  which  attaches 
itself  to  the  internal  condyle  of  the  femur  above,  and  to  the 
internal  part  of  the  head  of  the  tibia  below,  and  externally 
by  another  deep  process  to  the  external  condyle  of  the  femur 
above  and  to  the  head  of  the  fibula  below.  Underneath  this 
fascia  we  observe  the  muscular  and  articular  branches  of  the 
popliteal  or  posterior  tibial  nerve, — the  communicans  tibialis 
one  of  the  origins  of  the  external  saphenous  nerve, — the  en- 
trance of  the  posterior  or  external  saphena  vein  into  the  pos- 
terior part  of  the  popliteal  vein, — together  with  a  small  artery 
which  passes  through  an  opening  in  the  fascia  and  is  lost  in 
the  areolar  tissue  and  integuments;  all  these  may  be  seen 
tending  towards  the  surface  of  the  space  and  situated  between 
the  heads  of  the  gastrocnemius  muscle. 

The  popliteal  space  has  the  form  of  two  triangles,  the  bases 
of  which  are  united ',  or,  more  correctly  speaking,  the  base  of 
the  lower  is  received  within  the  base  of  the  upper  triangle, 
opposite  to  a  line  which  would  cross  from  one  condyle  of  the 

Fig.  B2  A.— A,  Tendon  of  the  Gracilis.  B.  The  Fascia  Lata.  C,  C,  Tendon  of  the  Semi -membra- 
nosus  Muscle.  D,  Tendon  of  the  Semi-tendinosus  Muscle.  E.E,  The  two  origins  of  the  Gastrocne- 
mius Muscle.  F,  The  Popliteal  Artery.  G,  The  Popliteal  Vein  joined  by  the  Posterior  Saphena  Vein. 
H,  The  Internal  division  of  the  great  Sciatic  or  the  Popliteal  Nerve.  I,  The  Peroneal  Nerve.  K,  K, 
The  Posterior  Tibial  Nerve,  the  continuation  of  the  Popliteal.  L.  The  Posterior  or  External  Saphena 
Vein.  M,  M,  The  Fascia  covering  the  Gastrocnemius  Muscle.  N,  The  Posterior  Saphenous  Nerve. 
O,  O,  The  Posterior  Tibial  Artery.  P,  Portion  of  the  Soleus  Muscle.  Q,  The  Tendon  of  the  Flexor 
Digitorum  Communis.  R,  Tendon  of  the  Flexor  Pollicis  Longus.  S,  Tendon  of  the  Peroneus 
liOngus.  T,  Peroneus  Brevis  Muscle.  U,  U,  The  Internal  Annular  Ligament.  V,  Tendo  Achillis. 
AV,  Tendon  of  the  Tibialis  Posticus  Muscle.   X,  The  A'eins  accompanying  the  Posterior  Tibial  Artery. 

Fig.  C2  B.—A,  C,  D,  E,  F,  G,  H,  I,  Same  as  in  Fig.  A.  B,  The  Internal  Condyle  of  the  Femur. 
K,  The  Plantaris Muscle  Iving  posterior  to  the  Popliteal  Artery  previously  to  its  bifurcation.  L,  Th? 
Popliteus  Muscle.  M,  M,  Tlxe  Tibia.  N,  N.  The  Fibula.  O,  O,  The  Posterior  Tibial  Artery.  P,  The 
Peroneal  Artery.    R,  S,  T,  T,  U,  U,  V,  W,  Same  as  in  Fig.  A.    X,  The  Astragalus. 

30* 


354  POPLITEAL   ARTERY. 

femur  to  the  other.  The  superior  triangle  is  bounded  by  the 
hamstring  muscles;  viz.,  on  the  outside  by  the  tendon  of  the 
biceps ;  and  on  the  inside  by  the  semi-membranosus  muscle, 
and  the  tendons  of  the  sartorius,  gracilis,  and  semi-tendi- 
nosus.  The  inferior  triangle  is  bounded  on  the  inside  by  the 
inner  head  of  the  gastrocnemius,  and  on  the  outside  by  the 
outer  head  of  the  gastrocnemius  and  the  origin  of  the  plan- 
taris  muscle :  the  origins  of  these  muscles  are  situated  be- 
tween the  inner  and  outer  hamstring  muscles.  The  fibular 
division  of  the  great  sciatic  nerve  may  be  seen  descending 
obliquely  outwards  between  the  tendon  of  the  biceps  muscle 
and  the  outer  head  of  the  gastrocnemius ;  in  this  situation  it 
becomes  flattened  and  expanded :  the  slender  tendon  of  the 
semi-tendinosus  muscle  may  also  be  observed  descending  be- 
tween the  inner  head  of  the  gastrocnemius  and  the  fibres  of 
the  semi-membranosus  muscle.  It  may  be  observed  that  the 
outer  boundary,  or  biceps  muscle,  is  tied  down  to  the  femur 
by  the  origin  of  its  short  head,  while  the  hamstring  muscles 
on  the  inside  have  not  the  same  close  attachment;  and  there- 
fore the  popliteal  space  is  more  open  in  this  direction.  The 
popliteal  or  posterior  tibial  nerve  descends  along  the  external 
margin  of  the  semi-membranosus  muscle :  in  front  of  the 
nerve,  and  occupying  the  centre  of  the  space,  we  find  the 
popliteal  vein,  and  still  more  in  front,  nearer  to  the  articulation 
of  the  knee,  we  find  the  popliteal  artery :  at  the  top  of  the 
space  both  of  these  vessels  are  overlapped  by  the  outer  portion 
of  the  semi-membranosus  muscle. 

THE   POPLITEAL   ARTERY. 

This  artery  extends  from  its  entrance  into  the  popliteal 
space,  through  the  opening  already  described,  to  the  lower 
margin  of  the  popliteus  muscle.  Situated  at  first  behind  the 
femur  above  its  internal  condyle,  it  runs  obliquely  downwards 
and  outwards,  and  terminates  inferiorly,  corresponding  to  the 
middle  line  of  the  limb.     Its  atiterior  surface  corresponds 


POPLITEAL   ARTERY. 


365 


superiorly  to  the  posterior 
surface  of  the  femur;  lower 
down,  to  the  ligamentum 
posticum  of  Winslowe, 
from  which  it  is  separated 
by  one  or  two  lymphatic 
glands;  and  still  lower 
down,  to  the  fleshy  fibres 
of  the  popliteus  muscle 
Throughout  its  extent  its 
posterior  surface  IS,  covered 
by  the  skin  and  superficial 
fascia,  and  by  the  popliteal 
fascia,  together  with  a  con- 
siderable quantity  of  adi- 
pose and  areolar  tissue  :  in 
the  upper  part  of  the  space 
it  is  covered  superiorly 
by  the  semi-membranosus 
muscle;  in  the  middle  of 
its  course  it  is  covered  by  its 
own  vein  and  by  the  popli- 
teal nerve,  frequently  by 


Fig.  Qi.— Arteries  of  the  Back  of 
the  Tliigh. 
1,  Glutaeal  Artery.  2,  3,  Its  superficial 
and  deep  Branch.  4,  Internal  Pudic  Ar- 
tery. 5,  Ischiatic  Artery.  6,  Branch  of 
the  External  Circumflex.  7,  8.  Terminal 
Branches  of  the  Perforating  Arteries.  9, 
Popliteal  Artery.  10,  11,  Superior  Inter- 
nal and  External  Articular  Arteries.  12, 
13,  Inferior  Internal  and  External  Arti- 
cular Arteries.  14,  Middle  Articular  Ar- 
tery. 15,  Gastrocncmial  branches,  a, 
Origin  and  insertion  of  the  Great  Glutaeal 
Muscle.  6,  Origin  of  the  Middle  Glutseal 
Muscle.  c,  Small  Gluteal  Muscle,  d. 
Great  Trochanter,  e.  Pyriforni  Muscle. 
/,  Sacro-sciatic  Ligaments,  g,  Internal 
Obturator  Muscle,  h.  Quadrate  Femoral 
Muscle,  i,  Sciatic  Nerve,  j.  Tuberosity 
of  the  Ischium,  fc,  External  Vastus  Mus- 
cle. I,  Great  Adductor,  m,  Short  Head 
of  the  Biceps,  n,  Long  Head,  o,  p.  Semi- 
membranous and  Semi-tendinous  Muscles. 
5,  Graclli.'.    r,  Gastrocnemius. 


35G  LIGATURE   OF    THE   POPLITEAL   ARTERY. 

a  lymphatic  gland,  and  inferiorly  by  the  internal  head  of 
the  gastrocnemius  muscle.  Its  vein  adheres  firmly  to  its  pos- 
terior surface,  projecting  a  little  to  its  external  side  above, 
but  to  its  internal  side  inferiorly :  the  popliteal  nerve  is  much 
more  superficial,  and  some  adipose  tissue  is  interposed  between 
it  and  the  vessels :  in  the  superior  part  of  this  space  the  nerve 
is  found  at  the  external  margin  of  the  semi-membranosus  mus- 
cle, and  therefore  external  to  the  artery,  while  inferiorly,  on 
account  of  the  ohlique  direction  of  the  artery ,  the  nerve  is  on  a 
plane  internal  to  it. 

The  student  would  do  well  to  attend  again  to  the  relative 
positions  of  the  popliteal  nerve  and  vessels  :  at  the  upper  part 
of  the  space,  and  passing  from  without  inwards,  he  will  find, — 
first  the  nerve,  then  the  vein,  and  more  internally  the  artery; 
about  the  centre  of  the  space,  that  is,  between  the  two  con- 
dyles, they  are  grouped  together,  and  do  not  lie  obliquely  with 
regard  to  each  other,  but,  passing  from  behind  forwards,  the 
nerve  is  most  superficial,  the  vein  lies  in  front  of  it,  and  still 
deeper  and  nearer  to  the  bone  we  find  the  artery.  At  the 
lower  part  of  the  space  these  parts  are  again  placed  obliquely 
with  regard  to  one  another, — the  nerve  is  found  most  inter- 
nally, the  vein  comes  next,  and  lastly,  most  externally,  we 
find  the  artery.  Notwithstanding  these  alterations,  through- 
out the  entire  of  the  space  the  nerve  lies  nearest  to  the  skin, 
the  artery  nearest  to  the  bone,  and  the  vein  corresponding  to 
a  plane  between  them  both. 

Ligature  of  the  Popliteal  Artery. — In  its  superior  third, 
this  artery  may  be  exposed  by  an  incision  on  the  external 
margin  of  the  semi-membranosus  muscle,  closely  applied  to 
whicl^  is  the  popliteal  nerve  :  the  muscle  being  drawn  in- 
wards, and  the  nerve  outwards,  the  vein  will  be  found  closely 
applied  to  the  posterior  or  cutaneous  surface  of  the  artery,  and 
projecting  a  little  to  its  outside :  great  caution  is  therefore 
necessary  in  separating  the  vessels  from  one  another,  and  the 
needle  should  be  passed  from  without  inwards. 


LIGATURE   OF   THE   POPLITEAL   ARTERY. 


357. 


The  popliteal  artery  may  be  secured  in  its  inferior  third  by 
a  vertical  incision  between  the  heads  of  the  gastrocnemius 
muscle.  The  posterior  saphenous  nerve  and  vein  being  drawn 
out  of  the  way,  the  popliteal  nerve  will  be  brought  into  view : 
deeper  and  more  externally  is 
the  vein,  and  still  deeper  and 
projecting  on  the  outside  of  the 
vein  is  the  artery.  The  nerve 
may  be  drawn  to  the  inside,  and 
the  vein  either  internally  or  ex- 
ternally, as  may  be  found  most 
convenient.  The  needle  is  to 
be  introduced  with  its  convexity 
to  the  vein. 

It  is  not  advisable  to  apply  a 
ligature  on  the  popliteal  artery 
in  the  middle  of  its  course,  on 
account  of  its  great  depth,  the 
unyielding  nature  of  its  lateral 
boundaries,  and  its  vein  and 
nerve  lying  so  directly  over  it. 


Fig.  64. — Represents  the  Superficial  Arteries 
of  the  Ham  and  of  the  Posterior  part  of  the 
Leg. 

1,  Vastus  Externus.    2,  2,  Tendon  of  the  Sartorius. 

8,  S,  Tendon  of  the  Gracilis.  4,  The  Semi-tendi- 
nosus.  5,  The  Senii-nienibrauosus.  6,  The  Biceps 
Muscle.    7,  TliePluntaris.    8, 8,  The  Gastrocnemius. 

9.  9.  The  Soleus.  10,  10,  The  Tendo  Achiilis.  11, 
The  Long  Flexor  of  the  Toes.  12,  Tendon  of  the 
Tibialis  Posticus.  13,  13,  Peroncus  Longus.  14,  14, 
Peroueus  Brevis.  1.5,  15,  The  Flexor  PoUicis  Lon- 
gus. 16,  Kxtensor  Digitorum  Brevis.  17,  Peroueus 
Tertius.  18,  Plautar  Aponeurosis.  19  Adductor  of 
the  Little  Toe.  20,  Popliteal  Artery.  21,  21,  Mus- 
cular Branches  from  the  Popliteal  Artery.  22, 
Branch  from  .\na.stomotica  Magna.  23,  Superior 
External  Articular  Artery  of  Knee.  24,  Superior 
Internal  Articular  Artery  of  Knee.  25,  A  Trunk 
sometimes  common  to  the  Inferior  Muscular  or  Sural 
vessels  of  the  calf.  26,  26,  26.  26,  26,  Arteries  of  the 
calf.  27,  Deep  Muscular  Twig.  28,  28,  Posterior 
Tibial  Artery.  29,  Muscular  Twig  from  Posterior 
Tibial  Artery,  30,  Branches  from  the  Internal  Mal- 
leolar Artery.  31,  31.  Muscular  Twigs  from  the 
Peroneal  Artery.  32,  The  Posterior  Peroneal  Artery. 
33,  Twig  from  the  preceding  Artery.  34.  Twig  from 
the  Posterior  Tibial  Artery.  .35,  Mranch  from  the 
Anterior  External  Malleolar  Artery.  36,  External 
Dorsal  Artery  of  little  toe. 


358  BRANCHES   OF   THE   POPLITEAL   ARTERY. 

The  branches  of  the  popliteal  artery  within  the  space  are 
the  following : — 

Superior  Internal  Articular.     Inferior  Internal  Articular. 

Superior  External  Articular.     Inferior  External  Articular. 
Muscular  branches. 
Azygos,  or  Middle  Articular  Artery, 
and  the  terminating  branches,  viz., 

Anterior  Tibial.  Posterior  Tibial. 

The  Superior  Internal  Articular  Artery  arises  under  cover 
of  the  semi-membranosus  muscle;  it  runs  upwards  and  for- 
wards and  arches  over  the  internal  condyle  of  the  femur,  be- 
tween that  bone  and  the  tendon  of  the  adductor  magnus ;  it 
terminates  in  two  branches,  one  of  which  supplies  the  vastus 
internus,  and  the  other  is  lost  on  the  inside  of  the  knee-joint: 
it  anastomoses  with  the  inferior  internal  articular  artery,  and 
with  the  anastomotic.  Two  superior  internal  articular  arteries 
have  been  described,  but  one  of  them  is  that  which  has  been 
mentioned  already  as  the  anastomotica  magna  branch  of  the 
femoral. 

The  Superior  External  Articular  Artery  passes  upwards 
and  outwards  and  arches  over  the  external  condyle  of  the 
femur,  between  that  bone  and  the  biceps  tendon.  It  termi- 
nates in  two  branches,  one  of  which  supplies  the  vastus  ex- 
ternus  muscle,  while  the  other  is  lost  on  the  outside  of  the 
joint.  It  communicates  with  the  anastomotic,  with  the  ex- 
ternal circumflexa  femoris,  and  with  the  inferior  external 
articular  artery. 

The  Inferior  Internal  Articular  Artery^  larger  than  the 
external,  runs  downwards  and  inwards,  along  the  superior 
margin  of  the  popliteus  muscle,  then  winds  round  the  inside  of 
the  neck  of  the  tibia,  covered  by  the  inner  head  of  the  gastroc- 
nemius, by  the  internal  lateral  ligament,  and  by  the  tendons  of 
the  sartorius,  gracilis,  and  semi-tendinosus  muscles.  It  is  lost 
in  the  structures  on  the  inner  side  and  front  of  the  joint. 

The  Inferior  External  Articular  Artery  comes  off  a  little 


BRANCHES   OF   THE   POPLITEAL   ARTERY.  359 

lower  down  than  the  preceding.  It  crosses  outwards  beneath 
the  external  head  of  the  gastrocnemius  muscle,  and  then 
turns  forwards  between  the  external  lateral  ligament  and  con- 
vex margin  of  the  external  semi-lunar  cartilage.  At  first  this 
artery  lies  on  the  posterior  surface  of  the  poplitcus  muscle, 
it  then  crosses  the  muscle  and  afterwards  lies  at  the  lower 
margin  of  its  tendon :  finally  it  terminates  in  two  branches, 
one  of  which  ascends  along  the  external  margin  of  the  patella, 
and  anastomoses  with  the  superior  external  articular  artery; 
the  other  descends  and  divides  into  two  branches,  one  of 
which  sinks  behind  the  ligamentum  patellaB,  and  is  lost  in 
the  fat  in  this  situation;  the  second  anastomoses  with  the 
tibial  recurrent. 

The  Muscular  branches  have  been  divided  into  two  sets,  the 
superior  and  the  inferior;  the  former  are  distributed  to  the 
muscles  forming  the  upper  boundaries  of  the  popliteal  space; 
the  latter,  called  the  sural  arteries,  are  distributed  to  the 
heads  of  the  gastrocnemii  and  plantaris  muscles.  The  popli- 
teal artery  also  gives  off  a  small  vessel  which  accompanies  the 
posterior  saphena  vein. 

The  Azi/gos  or  Middle  Articular  Artery  arises  from  the 
front  of  the  popliteal  artery,  consequently  will  be  best  seen 
after  the  other  branches  have  been  dissected :  it  runs  down- 
wards and  forwards,  and  pierces  the  posterior  ligament  of 
Winslowe,  to  supply  the  crucial  ligaments  and  condyles  of 
the  femur :  it  is  considerably  smaller  than  either  of  the  pre- 
ceding arteries. 

The  division  of  the  popliteal  artery  into  its  two  terminating 
branches,  the  anterior  and  posterior  tibial,  takes  place  at  the 
lower  border  of  the  popliteus  muscle ;  sometimes,  however, 
it  takes  place  above  this  point,  on  the  posterior  surface  of  the 
muscle. 

The  Anterior  Tibial  Artery. — This  artery  is  smaller 
than  the  postetior  tibial :  it  runs  at  first  somewhat  horizontally 


360 


ANTERIOR   TIBIAL   ARTERY. 


forwards  from  the  posterior  to  the  anterior  region  of  the  leg, 
through  a  foramen  above  the  interosseous  ligament:  this 
aperture  is  bounded  internally  by  the  tibia,  externally  by 
the  fibula,  which  is  sometimes  grooved  by 
the  artery,  superiorly  by  the  superior  tibio- 
fibular articulation,  and  inferiorly  by  the 
upper  fibres  of  the  interosseous  ligament, 
which  present  a  concave  margin  towards 
the  artery.  In  this  stage  of  its  course 
the  vessel  lies  close  to  the  fibula,  and  is 
occasionally  accompanied  by  a  small  nerve 
which  connects  the  posterior  with  the 
anterior  tibial  nerve :  it  then  descends 
obliquely  forwards,  and  nearly  parallel  to 
a  line  extending  from  the  head  of  the 
fibula  to  the  middle  line  of  the  ankle- 
joint.  In  the  rest  of  its  course  it  has  been 
called  by  some  the  Dorsalis  Pedis :  it  runs 
oigi  the  dorsum  of  the  foot  to  the  interval 
between  the  metatarsal  bones  of  the  great 
and  second  toes;  here  it  terminates  by 
dividing  into  two  branches,  viz. :  the  dor- 
salis pollicis  and  the  arteria  communicans. 


Fig.  65. — Represents  the  Superficial  Arteries  of  the  Ante- 
rior Aspect  of  the  Leg  and  Foot. 

1,  The  Patella.  2,  3,  External  and  Internal  portions  of  Triceps. 
4,  Tendon  of  Rectus.  5,  Ligameutum  Patellae.  6,  External  Lateral 
Ligament  of  Knee.  7,  Biceps  Muscle.  8,  Tendon  of  Sartorius.  9, 
Tibia.  10,  Malleolus  Internus.  11,  Malleolus  Externus.  12,  13,  14, 
Gastrocnemius  and  Soleus  Muscles.  15,  Tibialis  Anticus.  16, 
Long  Extensor  Muscle  of  the  Toes.  17,  Extensor  PoUicis  Proprius. 
18,  Peroneus  Longns.  19,  Peroueus  Brevis.  20,  Peroneus  Tertius 
or  Anticus.  21,  21,  21,  Extensor  Digilorum  Brevis.  22,  22,  Inter- 
ossei.  23,  Superior  External  Articular  Artei^  of  Knee.  24,  24, 
Branch  from  Superior  Internal  Articular  Artery  of  Knee.  25,  A 
Superficial  Branch  from  Inferior  Internal  Articular  Artery  of 
Knee.  26,  Branch  from  Inferior  External  Articular  Artery  of  Knee. 
27.  27,  Twigs  from  Anterior  Tibial  Recurrent.  28,  Arterial  Anasto- 
mosis over  the  Patella.  29,  29.  29,  Superficial  branches  from  Anterior 
Tibial  Arterr.  30,  Anterior  Peroneal  Artery.  31,  Anterior  Tibial 
Artery.  32,"Anterior  External  Malleolar  Artery.  33,  Twig  from 
Posterior  Internal  Malleolar  Artery.  34,  Twigs  from  Anterior  Internal 
Articular  Artery.  35,  Dorsal  Artery  of  Foot.  36,  Tarsal  Artery. 
The  doited  lines  intended  to  show  its  course  through  the  fibres  of 
the  short  Extensor  of  the  Toes.    37,  The  Dorsalis  Pollicis. 


LIGATURE  OP  THE  ANTERIOR  TIBIAL  ARTERY.         361 

In  its  course  down  the  front  of  the  leg  iis posterior  surface  rests, 
firstj  on  a  few  fibres  of  the  tibialis  posticus  which  accompany  the 
artery  through  the  opening;  then  on  the  interosseous  ligament, 
next  on  the  anterior  surface  of  the  inferior  extremity  of  the 
tibia,  and  lastly  on  the  astragulus,  scaphoid,  and  internal 
cuneiform  bones :  its  anterior  surface  is  covered  by  the 
anterior  tibial  nerve,  and  by  the  annular  ligament;  lower 
down  it  is  crossed  by  the  tendon  of  the  extensor  pollicis 
longus ;  and  near  its  termination,  by  the  internal  tendon  of 
the  extensor  brevis  digitorum :  its  internal  surface  corre- 
sponds, in  the  greatest  part  of  its  extent,  to  the  tibialis  anticus 
muscle:  the  external  surface  is  applied,  superiorly,  to  the 
fibres  of  the  extensor  longus  digitorum,  from  which  it  is  sepa- 
rated lower  down  by  the  fibres  of  the  extensor  pollicis,  the 
internal  surface  of  which  muscle  guides  the  anterior  tibial 
nerve  over  to  the  outer  side  of  the  artery.  The  tendon  of  this 
last  muscle  crosses  in  front  of  the  artery  on  the  dorsum  of  the 
foot,  to  get  to  its  inside,  and  then  the  vessel  is  once  more 
related  externally  to  the  extensor  longus  digitorum.  In  all 
this  course  the  artery  is  accompanied  by  two  venae  comites, 
one  on  either  side.  The  anterior  tibial  nerve  is  a  branch  of 
the  fibular,  which  winds  round  the  outside  of  the  head  of  the 
fibula,  passing  through  the  peroneus  longus  muscle,  and  meets 
the  outer  surface  of  the  artery  near  the  superior  extremity  of 
the  extensor  pollicis  muscle.  Thus  the  nerve  is  at  first  ex- 
ternal to  this  vessel,  then  lies  on  it  or  in  front  of  it,  and  infe- 
riorly  gets  a  little  to  its  inner  side. 

Ligature  of  the  Anterior  Tibial  Artery. — A  line  drawn 
downwards  from  the  prominent  portion  of  the  external  condyle 
of  the  tibia,  anterior  to  the  superior  tibio-fibular  articulation, 
would  correspond  to  the  tendinous  intersection  between  the 
tibialis  anticus  and  the  extensor  digitorum  communis  muscles; 
and  deeper  seated  still,  to  the  course  of  the  artery  when  it 

has  reached  the  front  of  the  leg.     If,  however,  the  upper 

31 


362  BRANCHES   OF   THE   ANTERIOR   TIBIAL. 

part  of  this  vessel  be  wounded,  the  wound  will  be  our  guide 
to  the  artery,  and  our  incisions  should  be  made  in  the  direc- 
tion of  the  fibres  of  the  muscles  in  this  situation  :  its  corre- 
sponding nerve  will  be  seen  lying  on  its  outside,  and  on  either 
side  is  a  small  vein.  At  the  front  of  the  instep  the  anterior 
tibial  artery  may  be  exposed  by  an  incision  made  between  the 
tendons  of  the  extensor  pollicis  longus,  and  extensor  digitorum 
communis.  We  may  expect  to  meet  in  this  operation,  first,  the 
internal  division  of  the  musculo-cutaneous  nerve,  and  then 
the  anterior  tibial  nerve,  which  either  lies  over,  or  is  a  little 
internal  to,  the  artery. 

The  branches  of  the  anterior  tibial  artery  are — 
Tibial  Recurrent.  External  Malleolar. 

Muscular  branches.  Tarsal. 

Internal  Malleolar.  Metatarsal  j 

and  the  terminating,  viz., 

Dorsalis  Pollicis.  Ramus  Communicans. 

The  Tibial  Recurrent  arises  from  the  anterior  tibial  artery, 
immediately  after  it  has  passed  through  the  interosseous  space : 
it  curves  upwards  and  inwards  through  the  fibres  of  the 
tibialis  anticus  muscle,  being  crossed  by  the  divisions  of  the 
tibial  recurrent  nerve :  it  spreads  its  branches  over  the  an- 
terior inferior  part  of  the  knee-joint  and  anastomoses  with  the 
inferior  articular  arteries. 

Several  Muscular  branches  are  given  off  from  the  anterior 
tibial  at  various  points  of  its  course  down  the  leg. 

The  Internal  Malleolar  is  given  off  immediately  above  the 
ankle-joint;  it  crosses  horizontally  inwards  behind  the  tendon 
of  the  tibialis  anticus  muscle,  spreads  its  branches  over  the  in- 
side of  the  articulation,  and  anastomoses  with  the  posterior  tibial. 

The  External  Malleolar,  larger  than  the  internal,  comes  off 
a  little  lower  than  the  last;  it  passes  outwards  behind  the 
extensor  digitorum,  extensor  pollicis,  and  peroneus  tertius 
muscles.     Its  branches  are  distributed  to  the  external  malleo- 


BRANCHES   OF   THE   ANTERIOR   TIBIAL. 


363 


,ii! 


lus,   and  to  the  outside  of  the  ankle-joint :    it   anastomoses 

with  the  tarsal,  the  external  plantar, 

and  the  peroneal  arteries.  ^\\li^>^  /' 

The  Tarsal  Branch  arises  as  the 
anterior  tibial  is  passing  over  the 
scaphoid  bone ;  it  runs  outwards 
through  the  fibres  of  the  short  ex- 
tensor of  the  toes,  and  passes  beneath 
the  tendons  of  the  long  extensor  and 
peroneus  tertius;  it  supplies  the  short 
extensor  and  articulations  of  the  tarsus, 
and  anastomoses  with  the  metatarsal, 
external  malleolar,  external  plantar, 
and  peroneal  arteries. 

The  Metatarsal  Branch,  smaller 
than  the  preceding,  proceeds  forwards 
and  outwards  through  the  fibres  of  the 
short  extensor,  forming  a  curvature 
the  convexity  of  which  looks  forwards, 
and  terminates  in  anastomosing  with 
the  two  small  arteries  last  described, 
and  with  the  external  plantar.  It  gives 
many  small  branches  to  the  articula- 
tions of  the  tarsus  and  to  the  short 
extensor  muscles.  Its  most  remark- 
able branches  arise  from  its  convexity : 
they  are  the  three  mterosseal  branches : 
they  run  forwards  over  the  muscles  fiU- 


Fig.  66,— Arteries  of  the  Front  of  the  Leg. 


1,  Anterior  Tibial  Artery.  2,  Recurrent  Tibial.  3,  Dorsal 
Pedal.  4, 5,  External  and  Internal  Malleolar  Arteries.  6,  Meta- 
tarsal Artery.  7,  Dorsal  Artery  of  the  Great  Toe.  8,  Terminal 
Branches  of  the  Articular  Arteries,  a.  Tibia.  6,  Anterior 
Tibial  Muscle,  c,  Extensor  of  the  Great  Toe.  d.  Long  Extensor 
of  the  Toes.  The  Short  Extensor  occupies  the  back  of  the  foot, 
e.  Peroneal  Muscles  :  on  each  side  of  the  leg  the  bellies  of  the 
Gastrocnemius  are  visible. 


364  POSTERIOR   TIBIAL   ARTERY. 

ing  the  second^  third  and  fourth  interosseous  spaces,  and,  having 
arrived  at  the  bases  of  the  phalanges,  each  of  them  divides 
into  two  small  branches.  In  this  manner  are  produced  six 
smaller  branches  which  supply  the  toes  from  the  internal 
margin  of  the  fifth,  to  the  external  margin  of  the  second. 
Opposite  the  posterior  extremities  of  the  metatarsal  bones, 
this  artery  communicates  with  the  posterior  perforating 
branches  of  the  external  plantar ',  and  opposite  their  anterior 
extremities  it  communicates  with  the  anterior  perforating 
arteries,  which  are  branches  of  the  inferior  digital. 

The  Dorsalis  PolUcis  advances  to  the  interosseous  space 
between  the  great  and  second  toes,  and  divides  into  two 
branches,  one  of  which  passes  under  the  extensor  tendons  of 
the  great  toe,  sinks  into  the  space  between  it  and  the  second, 
passes  obliquely  across  and  in  close  contact  with  the  under 
surface  of  the  first  metatarsal  bone,  and  is  lost  on  the  inner 
surface  of  the  great  toe,  anastomosing  with  the  internal  plantar 
artery :  the  other  branch  advances  as  far  as  the  cleft  between 
the  great  and  second  toes,  and  bifurcates  to  supply  the  ex- 
ternal margin  of  the  great  toe  and  the  internal  margin  of  the 
second. 

The  Ramus  Communicans  sinks  between  the  first  and 
second  metatarsal  bones,  and  is  continuous  with  the  termi- 
nating branch  of  the  external  plantar  artery. 

The  Posterior  Tibial  Artery. — This  vessel  may  be  ex- 
posed by  cutting  across  the  tendo  Achillis  at  its  upper  part, 
and  then  reflecting  the  gastrocnemius,  soleus,  and  plantaris 
muscles  upwards :  the  deep  tibial  fascia  may  now  be  divided 
and  the  artery  exposed.  It  extends  from  the  inferior  margin 
of  the  popliteus  muscle  to  the  fossa  between  the  internal 
malleolus  and  os  calcis :  in  this  course  it  is  directed  obliquely 
downwards  and  inwards.  Posteriorly  it  is  crossed  at  its  com- 
mencement by  a  tendinous  arch  connecting  the  two  origins 
of  the  soleus  muscle :  the  tendinous  character  of  this  arch 


POSTERIOR   TIBIAL  ARTERY. 


365 


will  be  well  seen  by  cutting  across  the  soleus  muscle  and 
turning  up  its  superior  portion,  so  as  to  expose  its  deep- 
seated  surface.  The  artery  is  covered 
in  the  upper  and  middle  third  of  the 
leg  by  the  fleshy  bellies  of  the  gas- 
trocnemius and  soleus,  by  the  plantaris 
tendon,  and  more  immediately  by  an 
aponeurosis  (the  deep  posterior  tibial 
fascia)  which  is  continuous  with  one 
of  the  expansions  of  the  tendon  of  the 
semi-membranosus  muscle.  11^  '     "       '^ 

In  the  inferior  third  of  the  leg  the 
artery  descends  along  the  internal  bor- 
der of  the  tendo  Achillis,  which  at  first 
covers  it  a  little,  but  lower  down  we 
find  it  covered  only  by  the  integuments 
and  three  layers  of  fascia,  viz.,  by  the 
deep  tibial  fascia  just  described,  by 
another  sent  ofi"  from  the  internal  mar- 
gin of  the  tendo  Achillis,  and  by  a 
third,  which  may  be  distinguished  by 
its  gliding  loosely  over  the  posterior 
surface  of  the  tendon.  Anteriorly  this 
artery  corresponds  successively,  from 
above  downwards,  to  the  tibialis  posticus 
muscle,  to  the  flexor  digitorum  com- 
munis, and  with  the  interposition  of 
some  areolar  tissue,  to  the  tibia.  It  is 
accompanied  by  two  venae  comites,  one 


Fig.  67. — Arteries  of  the  Back  of  the  Leg. 


1,  Popliteal  Artery.  2,  2,  Superior  Internal  and  External 
Articular  Arteries.  3,  3,  Inferior  Internal  and  External  Articu 
lar  Arteries.  4,  Middle  Articular  Artery.  5,  Gastrocnemial 
Arteries.  6,  Peroneal  Artery.  7,  Posterior  Peroneal  Branch.  8, 
Posterior  Tibial  Artery.  9.  Calcanean  Branches,  a,  Poplitea 
Muscle,  h,  c,  Origin  of  the  Gastrocnemius,  rf,  Peroneal  Muscles, 
e,  Long  Plexor  of  the  Great  Toe.  /,  Long  Plexor  of  the  Toes  : 
that  between  the  two  latter  is  the  Posterior  Tibial  Muscle. 

3r» 


366      LIGATURE   OF   THE   POSTERIOR   TIBIAL   ARTERY. 

on  eitlaer  side :  its  corresponding  nerve  is  internal  to  it  in  the 
upper  part  of  the  leg;  but  as  the  nerve  descends  it  crosses 
the  artery  superficially,  so  as  to  become  external  to  it  infe- 
riorly,  thus  separating  the  posterior  tibial  from  the  fibular 
artery. 

When  the  artery  has  arrived  in  the  fossa  between  the  os 
calcis  and  internal  malleolus,  it  is  accompanied  by  its  nerve, 
together  with  vessels,  and  tendons,  which  lie  in  the  following 
order;  commencing  at  the  internal  malleolus,  and  passing 
backwards,  we  find,  first,  the*  tendon  of  the  tibialis  posticus, 
then  the  tendon  of  the  flexor  longus  communis,  then  a  small 
vein,  then  the  artery,  then  another  small  vein,  next  the  pos- 
terior tibial  nerve,  and  nearest  the  os  calcis  the  tendon  of  the 
flexor  pollicis  longus. 

Ligature  of  the  Posterior  Tibial  Artery. — This  vessel  may 
be  secured  in  the  middle  part  of  its  course,  either  according 
to  Mr.  Guthrie's  plan,  by  a  long  incision  made  through  the 
gastrocnemii  muscles  and  deep-seated  fascia  down  to  the 
artery ;  or  by  the  following  proceeding : — the  patient  should 
lie  on  the  outside  of  the  limb,  with  the  knee  flexed,  and  the 
ankle  extended:  an  incision  is  then  to  be  made  about  four 
inches  long,  on  the  internal  margin  of  the  tibia,  taking  care 
to  avoid  the  saphena  vein.  The  inner  edge  of  the  gastrocne- 
mius muscle  is  then  to  be  detached  from  the  bone,  and  the 
tibial  origin  of  the  soleus  muscle  divided  on  a  director :  the 
strong  tibial  fascia  covering  the  vessel  is  now  brought  into 
view,  and  may  also  be  slit  up  on  a  director.  The  artery  will 
then  be  found  at  the  distance  of  about  an  inch,  or  an  inch 
and  a  half,  from  the  internal  edge  of  the  tibia.  The  nerve 
will  be  seen  crossing  over  towards  its  outer  side,  and  on  either 
side  of  it  will  be  found  a  vein. 

This  artery  may  also  require  to  be  tied  where  it  is  passing 
behind  the  internal  malleolus,  in  consequence  of  a  wound  to 
which  it  is  particularly  liable  amongst  ship-carpenters  in  the 


BRANCHES   OF   THE   POSTERIOR   TIBIAL.  367 

use  of  the  adze;  or  in  consequence  of  a  wound  of  a  large 
vessel  in  the  sole  of  the  foot.  For  the  purpose  of  securing 
the  vessel  in  this  situation,  an  incision  should  be  made  about 
four  inches  long,  nearly  midway  between  the  internal  malleo- 
lus and  tendo  Achillis.  This  incision  will  take  a  curved 
direction,  the  concavity  looking  towards  the  inner  malleolus : 
in  this  situation,  we  have  to  divide  successively  on  the  director 
the  three  layers  of  fascia  already  described :  the  artery  will 
then  be  exposed;  on  either  side  of  it  is  a  small  vein,  and 
behind  it,  or  nearer  to  the  tendo  Achillis,  is  the  posterior 
tibial  nerve.  The  needle  should  be  carried  under  the  artery 
from  behind  forwards. 

The  branches  of  the  posterior  tibial  artery  are  the  fol- 
lowing : — 

Muscular.  Peroneal. 

Nutritious.  Calcanean. 

Terminating,  viz. : 

Internal  and  External  Plantar. 

The  Muscular  Arteries  are  abundantly  distributed  to  the 
heads  of  the  gastrocnemius  and  soleus  muscles,  and  lower 
down  to  the  tendons  of  the  flexor  muscles,  and  to  the  perios- 
teum. 

The  Nutritious  Artery  or  Artery  of  the  Medullary  Mem- 
brane of  the  tibia  is  the  largest  of  the  kind  in  the  body :  it 
arises  from  the  posterior  tibial  shortly  after  its  origin  from 
the  popliteal,  it  passes  between  the  flexor  muscles  of  the  leg, 
then  grooves  the  posterior  surface  of  the  tibia,  and  enters  the 
nutritious  foramen,  running  downwards  towards  the  ankle 
through  an  oblique  canal  in  the  compact  tissue  of  the  bone, 
to  be  distributed  on  the  medullary  membrane. 

The  Peroneal  Artery  arises  from  the  posterior  tibial,  a  little 
below  the  commencement  of  the  latter,  and  then  inclines 
obliquely  downwards  and  outwards  to  reach  the  fibula,  along 
which  it  descends,  till  it  arrives  near  the  external  malleolus. 


368  LIGATURE   OF   THE   PERONEAL   ARTERY. 

Here  it  terminates  by  dividing  into  the  anterior  and  posterior 
peroneal.  In  this  course  the  peroneal  artery  usually  pierces 
the  superior  extremity  of  the  tibialis  posticus  muscle,  then 
lies  on  the  interosseous  ligament,  being  closely  applied  to  the 
fibula,  and  covered  by  the  flexor  pollicis  longus  muscle.  Its 
branches  are  distributed  to  the  surrounding  muscles  and  to 
the  integuments  and  periosteum.  In  the  inferior  fourth  of 
the  leg  it  sends  off  a  transverse  branch,  which  passes  inwards 
to  anastomose  with  the  posterior  tibial.  The  anterior  pero- 
neal artery  passes  forwards  through  a  foramen  in  the  inferior 
extremity  of  the  interosseous  ligament,  and  is  then  found  on 
the  front  of  the  limb  beneath  the  tendon  of  the  peroneus 
tertius  :  it  terminates  by  anastomosing  with  the  external  mal- 
leolar branch  of  the  anterior  tibial.  In  some  cases  this  artery 
is  very  small;  in  others,  on  the  contrary,  it  is  particularly 
large,  takes  the  place  of  the  anterior  tibial,  and  gives  off 
the  tarsal,  metatarsal,  dorsalis  pollicis,  and  communicating 
branches.  In  this  latter  case  the  anterior  tibial  is  small,  and 
ceases  by  communicating  with  the  anterior  peroneal  on  the 
front  of  the  ankle-joint.  The  posterior  peroneal  artery  de- 
scends behind  the  external  malleolus,  and  divides  on  the  out- 
side of  the  OS  calcis  into  a  number  of  branches,  which  supply 
the  periosteum,  adjacent  tendons  and  integuments,  and  anas- 
tomose with  the  tarsal,  metatarsal,  and  external  plantar  arte- 
ries. 

Ligature  of  the  Peroneal  Artery. — The  lower  part  of  the 
peroneal  artery  may  be  exposed  by  an  incision  commencing 
at  the  mid-point  between  the  tendo  Achillis  and  external 
malleolus,  and  extending  about  four  inches  upwards  and  out- 
wards towards  the  fibula.  The  fibres  of  the  flexor  pollicis 
longus  thus  exposed,  may  be  detached  from  the  fibula  as  far 
as  necessary,  and  the  muscle  drawn  inwards  ;  the  vessel  will 
then  be  observed  lying  on  the  interosseous  ligament  close  to 


PLANTAR  ARTERIES.  369 

the  fibula.  In  order  to  reach  this  vessel  Mr.  Hey  recom- 
mended sawing  out  a  portion  of  the  fibula. 

In  a  case  of  a  gunshot  wound,  Mr.  Guthrie  secured  it 
about  four  inches  below  the  head  of  the  fibula,  by  an  incision 
six  inches  long  through  the  gastrocnemius  and  soleus  mus- 
cles.* 

Corresponding  to  the  interval  between  the  two  origins  of 

Fig.  68. — Represents  the  Arteries  of  the  Internal  part  of  the  Foot  in  an  adult. 


1,  The  Soleus  Muscle.  2,  Tendo  Achillis.  3,  3,  Tendon  of  the  Plantaria.  4,  Peroneus  Brevis. 
5,  5,  Flexor  Uigitorum  Longus.  6,  6,  The  Flexor  PoUicis  Longus.  7,  Tendon  of  Tibialis  Posticus. 
8,  Tendon  of  Tibialis  Anticus.  9,  Extensor  Digitorum  Brevis.  10,  10,  Tendon  of  Extensor  PoUicis 
Proprius.  11,  11,  11,  Common  Extensor  Tendons  of  Toes.  12,  Short  Flexor  of  the  Toes.  13,  Ab- 
ductor Pollicis.  14,  A  branch  from  the  Posterior  Tibial.  15,  Internal  Malleolar  Artery.  16,  16, 
Tarsal  Artery.  17,  Posterior  Tibial  Artery.  18,  Internal  Plantar  Artery.  19,  A  superficial  branch 
of  same.  20,  20,  Anastomosis  between  the  preceding  artery  and  Tarsal  Artery.  21,  21,  Twigs  to 
Calcis.    22,  The  External  Plantar  Artery.   23,  Internal  Artery  of  Great  Toe,  or  Sixth  Digital  Artery. 

the  abductor  pollicis  muscle,  the  posterior  tibial  artery  termi- 
nates by  dividing  into  the  internal  and  external  plantar  arte- 
ries. Immediately  before  this  final  division  the  posterior 
tibial  artery  gives  ofi"  three  or  four  small  branches  called  the 
internal  calcanean,  which  supply  the  inner  part  of  the  os 
calcis  and  the  muscles  arising  from  it,  together  with   the 

*  Med.  Chir.  Trans.,  vol.  vii.  p.  234. 


370 


PLANTAR   ARTERIES. 


areolar   tissue  and   integuments  covering  the   parts  in  ttis 
situation. 

The  Internal  Plantar  Artery  is  a  branch  of  inconsiderable 
size :  it  advances  above  the  abductor  pollicis  pedis ;  and 
after  supplying  this  muscle,  and  the  flexor  pollicis  brevis, 
terminates  in  branches  which  are  distributed  to  the  integu- 
ments of  the  great  toe,  and  in  anastomosis  with  the  branches 
of  the  anterior  tibial  artery. 

The  External  Plantar  Artery,  much  larger  than  the  pre- 
ceding, passes  obliquely  forwards  and  outwards  towards  the 
base  of  the  fifth  metatarsal  bone :  in  this  the  first  part  of 
its  course,  it  nearly  follows  the  outer  margin  of  the  flexor 
digitorum  communis,  having  above  it  the  accessory  muscle, 
and  beneath  it  the  plantar  fascia  and  short  flexor  of  the  toes. 
In  the  second  part  of  its  course  it  lies  deeper,  and  passes 
forwards  between  the  flexor  brevis  and 
the  abductor  minimi  digiti,  and  then 
turns  inwards  through  a  triangular 
space,  bounded  in  front  by  the  trans- 
versalis  pedis,  'posteriorly  and  internally 
by  the  adductor  of  the  great  toe,  and 
externally  by  the  short  flexor  of  the  little 
toe;  the  interosseous  muscles  lie  above 
it,  and  the  common  flexor  tendons  beneath 
it :  its  corresponding  nerve  crosses  to  its 


Fig.  69. — Eepresents  the  Superficial  Arteries  of  the 
Sole  of  the  Foot  in  an  adult. 

2,  2,  2,  The  Plantar  Aponeurosis.  3,  3,  3,  3,  3,  3,  3,  Transverse 
bands  conneotiug  the  anterior  divisions  of  Plantar  Aponeurosis. 
4,  4,  4,  4,  5,  5,  5,  5,  5,  6,  6,  6,  6,  6,  6,  6,  6,  6,  6,  7,  7,  7,  Ligaments 
of  the  Plantar  Aspect  of  the  Toes.  8,  8,  Abductor  Pollicis  Mus- 
cle. 9,  Portion  of  the  Ple.\or  Pollicis  Brevis  Muscle.  10,  10,  Ab- 
ductor Minimi  Digiti  Muscle.  11,  11,  Tendon  of  the  Flexor  Pol- 
licis Longus.  12,  12,  12,  12,  Tendons  of  the  Short  Flexor  of  the 
Toes.  13,  13,  13,  13,  Tendons  of  the  Long  Plexor  of  the  Toes. 
14,  14,  Arterial  Anastomosis  on  the  Calcis.  15, 15,  Internal  Plan- 
tar Artery.  16,  16,  Internal  Digital  Artery  of  the  Great  Toe. 
17,  F>xternal  Plantar  Artery.  18,  First  or  Kxternal  Digital  Ar- 
tery of  Little  Toe.  19,  Second  Digital  Artery.  20,  Third  Digital 
Artery.  21,  Fourth  Digital  Artery.  22,  Fifth  Digital  Artery. 
23,  23,  23,  Arches  formed  by  the  Anastomosis  of  the  Digital  Ar- 


EXTERNAL  PLANTAR  ARTERY. 


371 


inside,  the  artery  being  superficial  at  the  crossing.  Finally, 
the  external  plantar  terminates  by  becoming  continuous  with 
the  communicating  branch  of  the  anterior  tibial  between  the 
metatarsal  bones  of  the  first  or  great  toe  and  of  that  next  to 
it,  thus  completing  the  plantar  arch  of  arteries.  From  this 
account,  it  follows  that  the  artery  is  deeply  seated,  and  de- 
scribes in  its  entire  course  a  curvature,  the  convexity  of  which 
looks  forwards  and  outwards  :  it  is  also  curved  to  accommodate 
itself  to  the  lateral  and  antero-posterior  arches  of  the  foot. 
In  the  foetus  and  young  subject,  the  ossification  of  the  tarsal 
and  metatarsal  bones  not  being  completed,  these  arches  of  the 
foot  do  not  exist,  and  the  artery  consequently  lies  nearer  to 
the  integuments. 

The  branches  of  the  external  plantar  artery  may  be  classed 
into  three  sets,  viz. : — 


Superior  or  Perforating; 

Posterior  and   Inferior,   or  Muscular; 

and  the 
Anterior  or  Digital. 

The  Superior  or  perforating  branches 
ascend  between  the  metatarsal  bones, 
and  anastomose  with  the  interosseous 
branches  of  the  metatarsal  artery. 


Pig.  70. — Represents  the  distribution  of  the  Arteries 
of  the  Sole  of  the  Foot.  Hie  Plantar  Aponeurosis 
and  the  Short  Flexor  of  the  Toes  have  been  removed. 

1,  Origin  or  the  Short  Flexor  of  the  Toes,  cut.    2,  2,  2,  2,  Ten- 
dons of  the  preceding  Muscle.    3,  3,  Abductor  Pollicis  Muscle.    4, 

4,  4,  4,  4,  4,  4,  4,  4,  Tendons  of  the  Long  Flexor  of  the  Toes.    5, 

5,  Accessory  Muscle.  6,  6,  Tendon  of  the  Flexor  Pollicis  Longus. 
7,  7,  7,  7,  The  Lumbricales.  8,  Portion  of  the  Short  Flexor  of  the 
Little  Toe.  9,  9,  10,  Abductor  Minimi  Digiti.  11,  Posterior  Ti- 
bial Artery.  12,  Branch  to  Calcis  from  preceding  Artery.  13, 
Branch  to  Calcis  from  Posterior  Peroneal  Artery.  14,  Internal 
Plantar  Artery.  15,  Sixth  Digital  Artery  or  Branch  to  the  inner 
side  of  Great  Toe  from  the  Dorsalis  Pollicis.  16,  External  Plan- 
tar Artery.  17,  First  Digital  Artery  running  along  the  outside 
of  Little  Toe.  18,  Second  Digital  Artery.  19,  Perforating  Twig 
from  the  preceding  Artery.  20,  21,  22,  Third,  Fourth,  and  Fifth 
Digital  Arteries.    23,  Dorsal  Twig.s  of  Great  Toe. 


372  DIGITAL   ARTERIES    OF   THE   FOOT. 

The  Posterior  and  inferior^  or  muscular  hrauches,  are  dis- 
tributed to  the  interosseous  muscles  and  lumbricales,  and  to 
the  tarso-metatarsal  articulations. 

The  Anterior  J  or  digital  arteries^  are  larger  than  the  pre- 
ceding, and  usually  four  in  number.  The  first^  or  most  ex- 
ternal, supplies  the  outer  edge  of  the  little  toe.  The  second, 
thirdj  and  fourth  advance  in  the  three  outer  interosseous 
spaces  till  they  reach  the  upper  surface  of  the  transversalis 
pedis  muscle :  here  each  of  them  sends  off  an  anterior  jper- 
forating  branch  which  communicates  with  the  corresponding 
interosseous  branch  of  the  metatarsal  artery :  after  this,  each 
of  the  digital  arteries  divides  into  two  digital  branches :  the 
digital  branches  from  the  second  supply  the  inner  surface  of 
the  little  toe  and  the  external  surface  of  the  opposite  toe; 
those  from  the  third  supply  the  inner  surface  of  the  fourth 
toe  and  the  outer  of  the  third;  and 
those  from  the  fourth  supply  the  inner 
surface  of  the  third  toe  and  the  outer 
of  the  second.  Thus  the  three  outer 
toes  and  the  outer  surface  of  the  second 
are  supplied  by  digital  branches  from 
the  external  plantar  artery;  whilst  the 
inner  and  outer  surfaces  of  the  great 
toe,  and  the  inner  surface  of  the  second, 
are  supplied  by  the  dorsalis  pollicis 
branch  of  the  anterior  tibial :  these  too 
may  be  termed  digital  branches,  that  one 
which  is  situated  in  the  most  internal 
interosseous  space  being  the  fifth  digital 
artery,  and  that  on  the  inside  of  the  great 

Fig.  71. — Arteries  of  the  Sole  of  the  Foot. 

1,  Posterior  Tibial  Artery  dividlnR  into  2,  the  Internal,  and  3, 
the  External  Plantar  Arteries.  4,  Branch  to  the  Inner  side  of 
the  Foot.  5,  Branch  to  the  Great  Toe.  6,  Plantar  Arch.  7,  Per- 
forating Arteries.  8,  Common  Digitals.  9,  Digitals  to  the  con- 
tiguous sides  of  the  Toes.  10,  Calcanean  Branches  of  the  Pero- 
neal and  Posterior  Tibial  Arteries. 


DIGITAL   ARTERIES   OP   THE   FOOT.  373 

toe  being  the  sixth.  As  in  the  fingers,  the  terminating 
branches  of  the  digital  arteries  which  run  at  each  side  of 
the  toes,  keep  up  a  free  anastomosis  with  each  other  at  the 
under  surface  of  each  of  the  ungual  phalanges :  each  anasto- 
mosis forms  an  arch  the  convexity  of  which  is  directed  for- 
wards. 


SOME  OP  THE  PEINCIPAL 

VARIETIES  OR  ANOMALIES  OF  THE  ARTERIES. 


VARIETIES   OR   ANOMALIES   OP   THE   PULMONARY  ARTERY. 

The  pulmonary  artery  may  arise  from  the  aorta,  or  in 
common  with  it;  or,  the  two  ventricles  may  communicate  at 
their  bases,  and  the  septum  between  the  aorta  and  pulmonary 
artery  may  be  deficient.  The  pulmonary  artery  has  been 
known  to  arise  from  the  left  ventricle,  and  the  aorta  from  the 
right :  in  such  cases  we  either  find  the  ductus  arteriosus  open, 
or  the  foramen  ovale,  or  both.  The  pulmonary  artery  may 
arise  from  the  left  ventricle,  the  right  being  almost  obliterated 
and  communicating  with  the  left.  The  pulmonary  artery  may 
give  off"  the  subclavian  artery.  In  a  case  related  by  Dr.  Farre, 
it  had  two  origins, — one  from  the  right,  and  the  other  from 
the  left  ventricle;  it  then  gave  off  the  descending  aorta, 
while  an  ascending  aorta  arose  directly  from  the  heart,  and 
supplied  the  head  and  upper  extremities.  In  cyanosis,  the 
pulmonary  artery  is  frequently  found  contracted  or  obliterated 
at  its  origin.  In  such  cases  the  blood  reaches  the  lungs 
by  passing  first  through  the  aorta,  then  through  the  ductus 
arteriosus,  and  so  into  the  right  and  left  pulmonary  arteries : 
the  bronchial  arteries  also,  by  means  of  their  communications 
with  the  pulmonary  arteries,  will  contribute  to  supply  the 
lungs. 

VARIETIES   OR   ANOMALIES   OP   THE   AORTA. 

The  varieties  of  the  commencement  of  the  aorta,  which 
we  shall  now  consider,  may  be  classed  into  those  relating  to 

374 


VARIETIES  OF  THE  AORTA.  375 

its  situation y  its  form,  its  course,  and  to  the  branches  which 
arise  from  it. 

1.  Varieties  as  to  the  Situation  op  the  Arch. — 
Mr.  Quain  mentions  one  case  in  which  the  arch  was  situated 
"but  a  little  below  the  level  of  the  top  of  the  sternum;" 
and  another,  in  which  it  was  so  low,  that  "  its  upper  margin 
corresponded  to  the  middle  of  the  fourth  vertebra." 

2.  Varieties  as  to  Form. — The  aorta  has  usually  at  its 
origin  the  form  of  an  arch :  in  some  cases,  however,  this  vessel 
has  been  observed  to  have  no  arch,  but  to  divide  soon  after 
its  origin  into  two  great  trunks,  one  of  which,  after  having 
ascended  for  some  distance,  gave  off  three  large  branches, 
presenting  the  form  of  a  cross,  one  branch,  the  continuation, 
which  became  the  left  carotid;  a  right  horizontal  branch 
which  was  the  arteria  innominata,  and  a  left  horizontal,  which 
became  the  left  subclavian :  the  other  great  trunk  became 
the  descending  aorta.  This  is  the  natural  arrangement  in 
the  horse,  ass,  sheep,  goat,  camel,  and  in  many  other  mammalia, 
especially  those  having  long  necks.* 

In  other  cases  the  aorta  bifurcates  as  above,  but  each  divi- 
sion gives  branches  to  the  head,  neck,  and  upper  extremity 
of  the  corresponding  side,  and  after  encircling  the  trachea 
and  oesophagus,  they  unite  to  form  the  descending  aorta. 
This  is  analogous  to  the  natural  structure  in  reptiles,  and  was 
first  described  by  Hammel. 

In  a  remarkable  case  described  by  Malacarne,  the  aorta 
arose  by  a  single  trunk  of  large  size,  and  contained  five  semi- 
lunar valves ;  it  then  divided  into  two  branches  immediately 
after  its  origin ;  these  two  formed  a  loop,  the  sides  of  which 
united  into  one  large  trunk  which  became  the  descending 


*  In  Abhandlungen  der  Josephinischen  Med.  Chir.  Acad.  Zuwien.  Band 
1,  s.  271-1787. 


376  VARIETIES  OF  THE  AORTA. 

aorta.  From  each  of  the  two  primary  branches  three  branches 
arose ;  the  first  the  subclavian,  the  second  the  external  carotid, 
and  the  third  the  internal  carotid.  Thus  in  this  case  there 
was  no  arteria  innominata.  There  are  two  specimens  in  the 
Museum  of  the  Royal  College  of  Surgeons  in  Ireland  of  the 
aorta  having /owr  valves  at  its  origin.  Mr.  Hunter  remarks, 
"  I  have  found  in  the  human  subject  only  two  valves  to  the 
aorta ;  but  this  is  very  rare."* 

A  very  singular  case  is  related  by  Gintrac,  in  which  the 
ascending  aorta,  which  arose  from  the  heart,  gave  branches 
to  the  head  and  upper  extremities;  while  the  descending 
aorta  was  a  continuation  of  the  pulmonary  artery. 

Lastly,  the  aorta  has  been  known  to  arise  by  two  roots,  one 
from  the  left  ventricle  and  the  other  from  the  right. 

Varieties  as  to  the  Course  op  the  Aorta. — In  some 
cases  the  aorta,  instead  of  crossing  to  the  left  side  of  the 
spine,  passes  backwards  towards  its  right  side,  and  then  either 
descends  on  the  same  side,  or  crosses  over  to  the  left  behind 
the  trachea  and  oesophagus."}"  In  other  cases  there  is  a  com- 
plete transposition  of  the  viscera;  and  the  direction  of  the 
heart  and  origins  of  its  great  vessels  are  altogether  reversed, 
the  systemic  cavities  of  the  heart  being  situated  at  the 
right  side,  and  the  pulmonic  on  the  left,  the  aorta  making 
its  arch  to  the  right  side,  and  descending  along  the  right  side 
of  the  spine  even  to  its  termination  in  the  iliac  arteries.  The 
vena  cava  in  these  cases  descended  on  the  left  side  of  the 
spine,  instead  of  on  the  right ;  the  left  carotid  and  left  sub- 
clavian arose  from  an  arteria  innominata,  on  the  right  side  of 
which  arose  separately  from  the  arch  the  right  carotid  and 
right  subclavian  arteries.  J 

•*  Treatise  on  the  Blood,  &c.,  p.  202. 
t  Meckel,  Anat.,  t.  ii.  p.  312. 

J  Phil.  Trans.  1793;  and  Houston's  Catalogue  of  Museum  of  Royal 
College  of  Surgeons,  Ireland,  p.  61. 


VARIETIES   OP  THE   AORTA.  377 

Varieties  as  to  the  Branches  of  the  Arch. —  Varie- 
ties with  two  primary  branches. — These  varieties  are  exceed- 
ingly numerous.  There  may  be  a  common  trunk  on  the  right 
side,  giving  off  the  right  subclavian,  and  both  carotids.  This 
is  the  natural  disposition  in  the  simiae,  and  has  been  also 
observed  in  the  dog,  fox,  wolf,  lion,  hyena,  bear,  and  many 
other  mammalia. 

There  may  be  a  common  trunk  on  the  left  side,  giving  off 
the  left  subclavian  and  both  carotids.  This  is  a  much  rarer 
variety  than  the  preceding. 

There  may  be  two  arteriae  innominatae,  one  giving  off  the 
right  common  carotid  and  subclavian,  and  the  other  giving 
off  the  left  common  carotid  and  subclavian.  This  is  the 
natural  arrangement  in  the  cheiroptera,  and,  according  to 
Cuvier,  occurs  in  the  dolphin.* 

There  may  be  a  left  arteria  innominata  giving  off  the  left 
carotid  and  subclavian,  while  the  right  carotid  comes  directly 
from  the  arch,  and  the  right  subclavian  comes  from  the  tho- 
racic aorta. 

Mr.  Green  remarks,  "  This  tendency  of  the  vessels  towards 
the  left  side  leads  to  an  anomaly  extremely  rare,  an  example 
of  which  I  have  before  me;  in  this  variety  all  the  vessels 
arise  from  the  left  side  of  the  arch.  First,  the  right  carotid, 
which  crosses  the  lower  part  of  the  trachea,  giving  off  the 
right  vertebral;  next  to  this  arose  the  left  carotid  and  sub- 
clavian, nearly  from  the  same  point ;  the  right  subclavian  is 
detached  from  the  back  part  of  the  arch  a  little  below  the 
left  subclavian :  it  passed  to  the  right  side,  behind  the  oeso- 
phagus and  trachea."f 

Lastly,  There  may  be  two  arteriaB  innominatae,  one  giving 
off  the  two  carotids,  and  the  other  the  two  subclavians. 

Varieties  with  three  primary  branches. — This  may  consist 

*  "  Lemons  d'Anatomie  Comparee/'  tome  iv.  p.  249. 
t  Varieties  of  the  Arteries,  p.  7. 
32^^ 


378  VARIETIES   OF   THE   AORTA. 

in  mere  transposition  of  the  vessels,  as  when  we  find  an 
arteria  innominata  on  the  left  side,  and  the  right  carotid  and 
subclavian  arising  separately  from  the  arch  without  any  other 
transposition.     This  is  very  rare. 

The  two  carotids  inay  arise  between  the  subclavians  by  a 
common  trunk.    This  is  the  regular  disposition  in  the  elephant. 

There  may  be  a  common  trunk  for  the  two  carotids ;  on  the 
left  side  of  this  may  be  the  origin  of  the  left  subclavian ;  and 
at  the  extremity  of  the  arch,  the  origin  of  the  right  sub- 
clavian. 

Lastly,  there  may  be  an  arteria  innominata  on  the  right 
side  for  the  right  subclavian,  and  the  two  common  carotids; 
on  the  left  side  of  this,  the  origin  of  the  left  vertebral ;  and 
still  more  to  the  left,  the  origin  of  the  left  subclavian. 

Varieties  with /our  'primary  hranches. — In  addition  to  the 
usual  branches,  there  may  be  a  left  vertebral  arising  between 
the  left  carotid  and  left  subclavian,  as  in  the  phoca  vitulina; 
or  a  left  vertebral  arising  beyond  the  left  subclavian  ]  or  an 
inferior  thyroid  artery,  usually  the  right  one,  arising  between 
the  innominata  and  left  carotid ;  or  a  middle  thyroid  artery, 
arising  in  the  same  situation ;  or  an  internal  mammary,  or  a 
thymic  branch,  arising  from  the  arch  of  the  aorta. 

The  right  subclavian  and  carotid  arteries  may  arise  sepa- 
rately from  the  arch,  in  which  case  the  right  subclavian  may 
be  the  first  branch;  or  the  right  subclavian  may  arise  between 
the  right  and  left  carotids;  or  between  the  left  carotid  and 
left  subclavian;  or  beyond  the  left  subclavian:  of  this  last 
variety  there  are  many  cases  on  record.  Mr.  Kirby  presented 
to  the  College  of  Surgeons,  in  this  city,  a  preparation  in  which 
a  piece  of  fish-bone  pierced  the  right  subclavian  artery  as  it 
passed  behind  the  oesophagus.*  This  artery  may,  however, 
pass  between  the  oesophagus  and  trachea,  or  even  in  front  of 

*  Houston's  Catalogue,  p.  79. 


VARIETIES   or  THE  AORTA.  379 

the  latter.  In  such  cases  the  inferior  laryngeal  nerve  of  this 
side  does  not  curve  under  the  right  subclavian  artery,  but 
after  its  origin  from  the  pneumogastric  nerve  in  the  lower 
portion  of  the  neck,  it  passes  directly  inwards  to  the  inferior 
part  of  the  larynx.  The  first  case  in  which  this  peculiar 
course  of  the  right  inferior  laryngeal  nerve  was  observed,  is 
related  by  Dr.  Stedman.*  The  next  case  is  related  by  Dr. 
Hart,  who  was  moreover  the  first  author  that  explained  the 
reason  of  the  deviation.  He  observes,  that  "in  the  earlier 
periods  of  the  existence  of  the  foetus,  the  rudiment  of  the 
head  appears  as  a  small  projection  from  the  upper  and  ante- 
rior part  of  the  trunk,  the  neck  not  being  yet  developed. 
The  larynx  at  this  time  is  placed  hehind  the  ascending  por- 
tion of  the  arch  of  the  aorta,  while  the  brain,  as  it  then 
exists,  is  situated  so  low  as  to  rest  on  the  thymus  gland,  and 
front  of  that  vessel.  Hence  it  is  that  the  inferior  laryngeal 
nerves  pass  back  to  the  larynx,  separated  by  the  ascending 
aorta, — the  left  going  through  its  arch,  while  the  right  goes 
below  the  arteria  innominata."f  Now  it  can  be  readily  under- 
stood how  the  ascent  of  the  brain,  as  the  neck  becomes  de- 
veloped, brings  higher  up  the  origins  of  the  recurrent  nerves; 
and  the  ascent  of  the  larynx  on  a  deeper  plane  brings  up 
their  terminations  in  that  organ,  so  that  they  are  made  to 
form  loops, — the  right  under  the  subclavian  artery,  and  the 
left  under  the  arch  of  the  aorta.  It  is  therefore  clear  that  if 
the  right  subclavian  artery  should  come  off  from  the  arch 
beyond  and  behind  the  left  subclavian,  and  pass  behind  the 
trachea  and  oesophagus,  or  even  between  the  two  in  order  to 
reach  the  right  side,  the  artery  will  be  situated  behind  the 
destination  of  the  nerve,  so  that  the  right  nerve  will  pass  at 
once  to  the  larynx  without  passing  under  the  right  subclavian 
artery.     Or  again,  should  the  right  subclavian  artery,  arising 


*  Edin.  Med.  and  Surg.  Jour,  for  1823. 
t  Same  Journal,  April,  1826. 


380  VARIETIES    OP   THE   AORTA. 

thus  irregularly,  pass  in  front  of  the  trachea  in  order  to 
reach  the  right  side,  and  in  its  course  be  placed  lower  down 
than  the  ordinary  situation  of  the  arteria  innominata,  the  right 
inferior  laryngeal  nerve  in  this  case  also  will  go  directly  to 
the  larynx  above  the  right  subclavian  artery.  It  is  therefore 
clear  that  in  all  such  cases  the  right  subclavian  artery  will 
not  have  the  effect  of  depressing  the  inferior  laryngeal  nerve 
of  the  right  side  into  the  form  of  a  loop  underneath  the  vessel. 

The  left  subclavian  may  be  the  first  branch  of  the  arch  on 
the  right  side;  and  after  that  may  arise,  in  succession,  the 
right  subclavian,  right  carotid,  and  left  carotid  arteries.  Or, 
lastly,  the  vessels  may  arise  from  the  arch  in  the  following 
order :  left  carotid,  right  carotid,  left  subclavian,  and  right 
subclavian  arteries. 

Varieties  witJi  five  primary  branches. — In  addition  to  the 
three  usual  branches,  the  left  vertebral,  and  the  right  internal 
mammary,  or  the  left  vertebral  and  right  inferior  thyroid, 
may  be  found  arising  from  the  arch ;  or  there  may  be  the 
three  usual  branches  with  two  vertebrals,  one  on  either  side 
of  the  left  carotid. 

The  subclavians  and  carotids  may  arise  separately  from  the 
arch,  with  a  common  trunk  for  the  left  vertebral  and  inferior 
thyroid;  or  with  a  right  inferior  thyroid  artery;  or  with  a 
left  vertebral,  in  which  case  the  right  subclavian  may  be 
either  the  first  or  last  branch. 

I  shall  have  occasion,  hereafter,  to  notice  particularly  a 
very  remarkable  case  which  I  observed  in  the  Carmichael  or 
Richmond  Hospital  School,  in  which  five  branches  arose 
from  the  arch,  in  consequence  of  the  subclavian  and  external 
and  internal  carotids  of  the  right  side  coming  off  separately 
from  the  aorta. 

Varieties  with  six  primary  branches. — The  subclavians, 
carotids,  and  vertebrals,  have  been  observed  to  arise  sepa- 
rately from  the  arch,  each  vertebral  being  between  the  sub- 
clavian and  carotid  of  its  own  side. 


VARIETIES   OP   THE   ARTERIA  INNOMINATA.  381 

Hence  it  appears,  that  omitting  the  coronary  arteries,  two 
is  the  smallest  number,  and  six  the  greatest  number  of  pri- 
mary branches  arising  from  the  arch :  these  extremes  are 
much  less  common  than  the  intermediate  numbers. 

Sometimes  varieties  with  regard  to  the  coronary  arteries 
have  been  observed ;  there  may  be  but  one ;  again,  there  may 
be  three,  or  even  four  ef  the  vessels  found.  These  deviations 
are,  however,  rare. 

VARIETIES    or   THE    ARTERIA    INNOMINATA. 

Some  of  the  irregularities  in  the  origin  of  this  vessel  have 
been  already  described  :  in  addition  it  may  be  remarked,  that 
it  has  been  seen  to  take  its  origin  from  the  descending  aorta. 
When  it  does  not  arise  from  the  arch  at  the  usual  place,  it 
must  necessarily  vary  in  its  course.  Velpeau  mentions  a 
curious  irregularity  of  this  vessel : — "  After  its  origin,  it 
passed  to  the  left,  in  order  to  turn  over  the  trachea,  then 
penetrated  between  this  organ  and  the  oesophagus,  and  re- 
placed itself  on  the  right  side  at  the  moment  of  its  bifurcation, 
but  much  more  deeply  than  in  the  natural  state."* 

In  some  cases  its  length  is  less,  and  in  others  greater  than 
what  we  have  described.  Guthrie  states  that  in  ordinary 
cases  the  artery  is  two  inches  and  a  half  in  length. 

Branches  of  the  Arteria  Innominata. — The  Middle 
Thyroid  of  JVeubaucr,  when  present,  usually  arises  from  this 
vessel :  the  inferior  thyroid  also  may  arise  from  it. 

VARIETIES    OF   THE   COMMON   CAROTID   ARTERY. 

Some  years  back  I  observed  a  very  remarkable  variety  in 
a  subject  at  the  Carmichael,  then  the  Richmond  Hospital 
School  of  Medicine :  in  this  subject  there  was  no  common 
carotid  on  the  right  side ;  and  the  external  and  internal  caro- 

*  Velpeau's  Surg.  Anat.,  American  Trans.,  p.  433. 


382      VARIETIES    OF   THE   COMMON    CAROTID   ARTERY. 

tids  arose  separately  from  the  arch  of  the  aorta.  The  order 
of  the  vessels  was, — right  subclavian,  right  external  carotid, 
right  internal  carotid,  left  common  carotid,  left  subclavian. 
I  showed  this  preparation  to  the  younger  Tiedemann  when 
he  visited  the  school,  and  he  remarked,  that  no  similar  case 
had  been  observed  or  heard  of  by  himself  or  his  father.  Mr. 
Harrison  states  that  he  has  known  two  examples  of  the  inter- 
nal and  external  carotids  arising  on  one  side  separately  from 
the  aorta. 

In  some  cases  the  common  carotid  is  crossed  in  front  by 
the  inferior  thyroid  artery.  In  other  cases  the  vertebral 
artery  ascends  behind  it  to  pierce  the  third  or  second  cervical 
vertebra.  Cases  are  recorded  in  which  the  common  carotid 
ascended  behind  the  angle  of  the  lower  jaw  before  it  bifur- 
cated; and  on  the  other  hand,  it  may  bifurcate  as  low  as 
the  inferior  margin  of  the  thyroid  cartilage,  or  at  the  sixth 
cervical  vertebra :  lastly,  it  sometimes  happens,  that  there  is 
no  bifurcation, — the  common  carotid  and  internal  carotid 
forming  a  continuous  trunk,  which  gives  off  the  branches 
of  the  external  carotid.  The  common  carotid  may  give  off 
the  inferior  thyroid,  superior  laryngeal,  pharyngea  ascendens, 
superior  thyroid  and  right  vertebral  arteries. 

.  Varieties  op  the  Superior  Thyroid  Artery. — This 
artery  sometimes  arises  by  a  trunk  common  to  it  and  the  lin- 
gual, or  it  may  arise  directly  from  the  common  carotid :  in 
some  cases  the  common  carotid,  instead  of  bifurcating,  divides 
into  three  branches,  the  internal  carotid,  the  external  carotid, 
and  the  superior  thyroid. 

Varieties  op  the  Occipital  Artery. — In  some  cases 
this   artery  arises   from   the   internal    carotid.*     Dr.  Green 

*  Tiedemann,  Exp.  Tab.  Art.,  p.  81. 


VARIETIES   OP  THE   INTERNAL   CAROTID   ARTERY.     383 

relates  a  case  in  which  it  arose  from  the  vertebral.*     Lastly, 
it  may  give  off  the  pharyngea  ascendens.f 

Varieties  op  the  Posterior  Auricular  Artery. — 
This  artery  sometimes  arises  by  a  trunk  common  to  it  and 
the  occipital.     It  sometimes  gives  off  the  transversalis  faciei. 

Varieties  of  the  Pharyngea  Ascendens  Artery. — 
The  pharyngea  ascendens  is  sometimes  a  branch  of  the  com- 
mon carotid  artery,  and  in  still  rarer  cases  it  may  arise  from 
the  internal  carotid,  in  which  case  there  is  usually  an  acces- 
sary pharyngeal  from  the  external  carotid.  It  has  also  been 
observed  to  arise  from  the  occipital,^  or  from  the  superior 
thyroid,§  or  facial.  1|  Finally,  there  are  sometimes  two,  and 
at  other  times  three,  instead  of  a  single  artery.^ 

Varieties  op  the  Transversalis  Faciei  Artery. — 
In  many  cases  this  artery  arises  from  the  temporal.  Dr.  Hart 
has  seen  it  arise  from  the  external  carotid,  opposite  the  angle 
of  the  jaw,  beneath  which  it  passed  forwards  and  joined  the 
labial  at  the  anterior  edge  of  the  masseter  muscle.  He  has 
also  seen  it  arise  from  the  posterior  auricular.  When  the 
facial  artery  is  small,  this  vessel  is  proportionally  large,  and 
gives  off  the  dorsalis  nasi  or  angularis  artery,  or  both. 

VARIETIES   OP   the   INTERNAL   CAROTID   ARTERY  AND   ITS 

branches. 
We  have  already  observed  that  the  external  carotid  is  some- 
times deficient,  in  which  case,  the  internal  is  a  continuation 
of  the  common  carotid,  and  gives  off  the  branches  which 
usually  arise  from  the  external ;  and  that  it  sometimes  arose 


*  Green,  p.  10.  f  Op.  Cit.,  p.  9. 

J  Cruveilhier,  Ang.,  p.  102.  §  Meyer,  Lehre  von  der  Blut,  p.  49. 

II  Green,  p.  9.  f  Soemmering,  Op.  cit.  p.  126. 


384  VARIETIES   OF  THE   SUBCLAVIAN   ARTERY. 

near  the  base  of  the  skull.  In  many  cases  we  find  that  at 
the  side  of  the  sella  turcica  it  passes  through  a  foramen  formed 
by  the  existence  of  a  middle  clinoid  process,  or  spicula  of 
bone  connecting  the  tip  of  the  anterior  clinoid  process  to  the 
side  of  the  body  of  the  sphenoid  bone.  In  some  cases  its 
anterior  branch  to  the  cerebrum  unites  directly  with  that  of 
the  opposite  side,  instead  of  being  connected  with  it  by  one  or 
more  transverse  branches,  and,  after  a  short  course,  the  com- 
mon trunk  divides  into  two  branches.  Occasionally  its  poste- 
rior communicating  branch  is  of  considerable  size,  and  its 
continuation  forms  the  posterior  artery  of  the  cerebrum,  being 
connected  to  the  basilar  trunk  by  a  short  branch.  There  are 
cases  on  record,  in  which  Haller  had  observed  the  two  anterior 
arteries  of  the  cerebrum  furnished  by  the  carotid  of  one  side, 
and  the  two  middle  arteries  of  the  cerebrum  furnished  by  the 
carotid  of  the  opposite  side. 

VARIETIES    OF   THE   SUBCLAVIAN   ARTERY. 

In  addition  to  the  great  number  of  varieties  already  noticed, 
we  shall  only  add,  in  this  place,  that,  in  some  cases,  the  sub- 
clavian artery  passes  in  front  of  the  scalenus  anticus  muscle 
along  with  the  vein,*  whilst,  on  the  other  hand,  this  latter 
vessel  may  be  found  behind  the  muscle  together  with  the 
•  artery.  Both  of  these  varieties  have  been  observed  by  Vel- 
peau.  M.  Robert  has  observed,  that  the  little  scalenus,  when 
present,  in  passing  to  its  insertion  into  the  rib,  frequently 
separates  the  two  inferior  fasciculi  of  the  brachial  plexus, 
and  pushes  them  forwards  against  the  artery.  In  some  cases, 
the  muscular  relations  differ :  the  omo-hyoid  muscle  may  have 
an  additional  origin  from,  or  attachment  to,  the  clavicle. 

Bouillaud  mentions  that  Breschet  observed  a  very  remark- 
able anomaly,  in  which  the  left  subclavian  artery  arose  from  the 
pulmonary  artery.     In  some  cases  the  thyroid  axis  is  deficient, 

•»  Hird,  Lond.  Med.  Gazette,  Feb.  4,  1837. 


VARIETIES   OP   BRANCHES    OF   THE    SUBCLAVIAN.      385 

and  its  usual  branches  arise  by  two  or  more  separate  trunks. 
In  its  third  stage,  the  subclavian  frequently  gives  off  the  pos- 
terior scapular.  Professor  Hargrave  has  seen  the  internal 
mammary  arise  in  this  situation  and  descend  in  front  of  the 
scalenus  anticus  muscle. 

Varieties  or  the  Vertebral  as  to  its  origin  have 
been  alluded  to  on  page  380. 

Varieties  of  the  Internal  Mammary  Artery. — This 
artery  may  arise  from  the  arch  of  the  aorta,  arteria  inno- 
minata,  thyroid  axis,  and  even  from  the  third  stage  of  the 
subclavian,  as  observed  by  Professor  Hargrave.  Bichat  has 
seen  its  comes  nervi  phrenici  branch  as  large  as  the  trunk  of 
the  internal  mammary,  and  Cruveilhier  met  a  subject  in  which 
its  third  intercostal  branch  was  large  enough  to  appear  a 
bifurcation  of  it. 

Varieties  of  the  Posterior  Scapular  Artery. — We 
have  already  seen  that  this  artery,  in  its  normal  state,  arises 
from  the  thyroid  axis,  but  that  sometimes  it  arises  from  the 
subclavian  in  its  third  stage;  in  such  cases  it  may  pass 
through  the  brachial  plexus  of  nerves,  and  take  its  ordinary 
place  along  the  vertebral  margin  of  the  scapula.  In  cases 
of  this  description  of  variety,  the  cervicalis  superficialis,  as 
already  stated,  forms  a  distinct  branch  of  the  thyroid  axis. 

Varieties  of  the  Subscapular  Artery. — This  artery 
sometimes  arises  in  common  with  the  posterior  circumflex,  and 
Dr.  Monro  has  seen  it  arising  from  the  inferior  thyroid. 

Varieties  of  the  Posterior  Circumflex  Artery. — In 
some  cases  this  artery  winds  round  the  humerus  by  passing 
beneath  the  tendons  of  the  teres  major  and  latissimus  dorsi, 

33 


386  VARIETIES   OP   THE   BRACHIAL   ARTERY. 

and  not  through  the  quadrangular  space  already  described. 
In  such  cases  it  usually  gives  off  the  superior  profunda  artery. 

VARIETIES   OF   THE   BRACHIAL   ARTERY. 

The  most  common  irregularity  of  the  brachial  artery  is  a 
high  bifurcation  into  the  ulnar  and  radial.  This  may  occur 
in  any  part  of  its  course.  In  this  case  the  ulnar  and  radial 
arteries,  having  arrived  in  the  fore-arm,  may  pursue  their 
usual  course ;  or  the  radial  may,  in  certain  cases,  run  super- 
ficially, or  the  ulnar  may  be  the  superficial  branch :  usually, 
however,  in  these  irregularities,  the  ulnar  follows  the  ordinary 
deep  course  of  the  brachial  artery.  Mr.  Burns  observes,  that, 
when  the  ulnar  is  the  anomalous  branch,  the  bifurcation 
usually  takes  place  higher  up  than  when  the  radial  is  irregular. 

In  the  high  bifurcation,  the  radial  artery  usually  lies  at 
first  on  the  inside,  and  afterwards  crosses  the  ulnar,  or  con- 
tinued trunk,  to  become  external.  These  two  vessels  may  be 
connected  in  their  course  by  a  transverse  branch ;  and  the 
transverse  branch  may  give  off  a  median  artery ,  which 
descends  on  the  front  of  the  fore-arm  in  company  with  the 
median  vein:  in  other  cases,  the  median  artery  may  come 
from  the  brachial,  radial,  or  ulnar :  it  usually  terminates  in 
the  superficial  palmar  arch,  sometimes  in  the  deep  one. 

Dr.  Quain  mentions  a  remarkable  instance,  in  which  the 
brachial  artery  divided  into  two  branches,  and,  lower  down, 
reunited  to  form  a  single  trunk,  which  afterwards  bifurcated 
regularly  into  the  radial  and  ulnar.*  A  similar  instance  is 
recorded  by  Professor  Quain  ;f  and  a  preparation  of  the  same 
kind  of  irregularity  exists  in  the  Macartney  collection  in  the 
Anatomical  Museum  of  the  University  of  Cambridge.  Mr. 
Norton,  of  the  Royal  Liverpool  Institution,  has  met  with  a 
similar  case.  Dr.  Geddings,  of  Maryland,  in  speaking  of  the 
varieties  of  the  brachial  artery,  observes,  "  In  some  instances 

*  Elements  of  Anatomy,  4th  edition,  p.  558. 

f  Anatomy  of  the  Arteries  of  the  Human  Body,  p.  221. 


VARIETIES  OF  THE  ULNAR  AND  RADIAL  ARTERIES.      387 

the  radial  and  ulnar  arteries,  after  separating  high  in  the  arm, 
or  axilla,  pass  for  a  limited  distance  down  the  arm,  and  then 
unite/'  He  gives  no  reference,  however,  but  may  possibly 
allude  to  the  following  passage  in  the  work  of  Dr.  Green, 
who  is  quite  explicit  on  the  subject: — "Sometimes  the 
axillary  artery  divides  into  two  vessels  which  again  unite  at 
the  fold  of  the  arm,  so  that  there  are  in  reality  two  brachial 
arteries  lying  close  to  one  another,  and  of  equal  magnitude. 
I  have  seen  two  striking  examples  of  this  kind.  In  one  case, 
the  brachial  divided  into  two  branches,  which  in  like  manner 
conjoined  above  the  fold  of  the  arm."* 

In  three  cases  out  of  forty.  Professor  Harrison  found  "  a 
small  branch  arising  from  the  upper  part  of  the  brachial  and 
descending  to  the  elbow,  where  it  joined  the  radial  artery;  in 
two  instances  this  superficial  branch  descended  in  the  fore- 
arm beneath  the  superficial  flexors,  and  was  distributed  to 
the  muscles  in  this  region ;  and  in  two  cases  it  accompanied 
the  brachial  nerve  beneath  the  annular  ligament  of  the  carpus, 
and  joined  the  superficial  palmar  arch  of  arteries."f  These 
have  been  described  under  the  name  of  "  vasa  aberrantia :" 
they  are  frequently  of  considerable  size. 

The  next  variety  to  be  noticed  is  that  of  the  brachial  artery 
giving  ofi"  the  interosseal :  a  case  of  this  kind  has  been  ob- 
served by  Dr.  Flood  in  the  Richmond  Hospital  School.  In 
some  rare  cases  the  brachial  artery  divides  at  one  point  into 
three  branches,  viz.,  the  radial,  ulnar,  and  interosseous. 

Varieties  of  the  Ulnar  and  Radial  Arteries. — 
The  origin  of  either  vessel  in  the  arm  or  axilla  has  been 
already  noticed.  Sometimes  the  ulnar  artery  arises  regularly 
at  the  bend  of  the  elbow,  yet  afterwards  it  descends  on  the 
cutaneous  surface  of  the  muscles  arising  from  the  internal 
condyle,  and  accompanies  the  basilic  vein.     The  radial  artery 

*  Green  on  the  "  Varieties  in  the  Arterial  System,"  p.  17. 
t  Surgical  Anatomy  of  the  Arteries,  p.  192. 


388      VARIETIES  OF  THE  ULNAR  AND  RADIAL  ARTERIES. 

may  also,  though  regular  in  its  origin,  run  superficial  to  the 
fascia.  These  latter  irregularities  are  very  rare.  Dr.  Green, 
when  speaking  of  the  irregular  origin  of  the  ulnar  high  up  in 
the  arm,  observes,  "  it  pursues  its  course  along  the  fore-arm, 
immediately  under  the  fascia."* 

He  remarks  also,  concerning  the  irregular  origin  of  the 
radial,  that  "  in  some  rare  instances  the  vessel  pierces  the 
brachial  aponeurosis,  and  becomes  quite  superficial ;  but  more 
usually  it  is  covered  by  the  tendinous  expansion."  He  states 
that  he  has  seen  but  one  instance  of  the  irregular  radial  lying 
superficial  to  the  fascia  :■{"  Tiedemann  makes  the  same  remark.J 

Dr.  Barclay  describes  a  case  in  which  both  radial  and  ulnar 
were  superficial.  Dr.  G-reen  saw  a  case  in  which  a  transverse 
branch  joined  the  radial  and  ulnar  at  the  lower  third  of  the 
fore-arm.  Sometimes  the  radial  artery  gives  ofi"  the  superfi- 
cialis  volae  high  up  in  the  fore-arm :  this  is  more  likely  to 
occur  in  case  of  a  high  bifurcation  of  the  brachial.  If  the 
superficialis  volae  arise  high  up,  the  continued  trunk  of  the 
radial  may  either  descend  along  with  it  and  on  a  deeper  plane, 
or  may  turn  round  the  radius  near  the  lower  third  of  the  fore- 
arm, and  descend  in  this  region  to  the  hand.  Dr.  Green  saw 
two  cases  of  this  description. 

In  addition  to  the  above,  we  may  quote  the  following  re- 
markable variety,  observed  by  Mr.  Bennett  Lucas  at  the 
North  London  School  of  Medicine  : — 

"  A  female,  aged  seventy,  exhibited  in  the  distribution  of 
her  arteries  the  most  uniform  irregularity.  Those  of  the 
upper  extremities  I  have  alone  preserved,  as  they  are  highly 
interesting  in  a  practical  point  of  view.  The  brachial  artery 
of  the  right  side  bifurcated  as  usual  at  the  bend  of  the  elbow 
into  radial  and  ulnar  arteries ;  but  the  radial  was  infinitely 
the  larger.     The  ulnar  artery,  after  running  its  usual  course 


*  Green  on  the  "  Varieties  in  the  Arterial  System,"  p.  21. 
t  Op.  Cit.,  p.  19.  X  Tied.  Tab.  Art.,  p.  169. 


VARIETIES  OF  THE  ULNAR  AND  RADIAL  ARTERIES.      389 

for  about  two  inches,  suddenly  sent  off  a  leash  of  branches  ; 
viz.,  a  large  recurrent,  several  fair-sized  muscular,  a  huge 
interosseal,  which  ran  down  to  terminate  in  the  deep  palmar 
arch,  and  a  middle-sized  ^  continued  trunk,^  which  lost  itself 
in  the  superficial  palmar  arch,  as  it  scarcely  could  be  said  to 
assist  in  its  formation.  The  great  radial  trunk  went  its  way, 
detaching  few  and  insignificant  twigs,  and  a  quarter  of  an 
inch  above  the  wrist-joint  sent  off  a  superficialis  volae,  more 
as  a  matter  of  form  than  any  thing  else,  for  it  soon  expended 
itself  in  the  muscles  of  the  thumb.  The  undiminished  trunk 
of  the  radial  now  turned  round  the  outer  edge  of  the  carpus, 
and,  at  the  angle  formed  by  the  metacarpal  bones  of  the 
thumb  and  index  finger,  sent  off  two  branches,  the  larger  of 
which  (the  other  being  spent  in  the  adductor  pollicis  and  ab- 
ductor indicis  muscles)  coursed  along  the  inner  edge  of  the 
metacarpal  bone  of  the  thumb,  furnishing  the  princeps  pollicis, 
radialis  indicis,  and  a  retrograde  branch,  to  form,  with  the 
nearly  exhausted  ulnar  artery,  the  superficial  palmar  arch. 
From  this  arch  proceeded  four  branches,  the  smaller  of 
which  went  to  the  inner  edge  of  the  little  finger,  the  next 
bifurcated  to  supply  the  opposed  sides  of  the  little  and  ring 
fingers,  the  third  bifurcated  to  supply  the  opposed  sides  of 
the  ring  and  middle  fingers,  but  the  fourth,  a  pitiable  vessel, 
ran  to  the  head  of  the  third  metacarpal  bone,  and  there  joined 
a  large  digital  trunk  derived  from  the  deep  palmar  arch.  The 
continued  trunk  of  this  radial  artery,  at  length  sensibly 
diminished,  took  its  usual  course  to  form  the  deep  palmar 
arch.  At  the  proximal  end  of  the  metacarpal  bone  of  the 
index  finger,  the  large  digital  artery,  already  alluded  to 
(merely  acknowledging  the  receipt  of  the  fourth  superficial 
palmar  artery),  bifurcated  to  supply  the  opposed  sides  of  the 
middle  and  index  fingers.  After  forming  the  deep  palmar 
arch,  which  sent  off  the  usual  arteries  to  the  smaller  palmar 
muscles,  the  radial  trunk  ran  under  the  cover  of  the  muscular 
mass  of  the  little  finger,  sending  numerous  branches  therein, 


390       VARIETIES  OF  THE  ULNAR  AND  RADIAL  ARTERIES. 

and  then  playfully  turned  upwards  under  the  annular  liga- 
ment, and  united  with  the  large  interosseal  artery  from  the 
ulnar. 

"In  this  very  uncommon,  if  not  unique,  distribution  of 
arteries,  we  find  the  radial  (a  huge  trunk)  taking  its  usual 
course,  and  supplying  the  palm  of  the  hand  and  all  the  fingers. 
Intent  upon  this  purpose,  it  sends  off  but  few,  and  these 
small,  muscular  branches,  and  a  superficialis  volse  of  no 
account;  and,  merely  condescending  to  make  an  intimacy 
with  the  ulnar  and  interosseal  arteries,  it  takes  upon  itself, 
not  alone  to  form  the  superficial  palmar  arch,  but  to  form  it 
much  less  in  extent  than  the  deep  palmar  arch, — the  arch 
which  it  forms  in  the  natural  distribution,  and  which  is  in 
such  case  much  the  smaller. 

"On  the  left  side  of  this  subject  the  brachial  artery 
divided  as  usual ;  but  here  the  ulnar  artery  was  very  large 
and  the  radial  artery  very  small.  The  radial,  immediateli/  after 
its  origin^  sent  off  the  superficialis  vol86,  which  vessel,  though 
nearly  the  length  of  the  fore-arm,  was  very  delicate,  and, 
after  detaching  several  small  muscular  branches,  lost  itself  in 
the  muscles  of  the  thumb,  without  participating  in  the  forma- 
tion of  the  palmar  arch.  In  its  course,  it  occupied  the  posi- 
tion of  the  radial  artery.  The  radial  trunk  itself  ran  very 
superficially,  and,  at  the  junction  of  the  middle  and  inferior 
thirds  of  the  fore-arm,  turned  round  the  edge  of  the  radius  to 
the  space  between  the  metacarpal  bones  of  the  thumb  and 
index  finger,  where  it  sent  off  the  palmaris  profunda  to  form 
the  deep  palmar  arch  in  the  usual  manner,  the  radialis  indicis 
and  the  princeps  pollicis,  and,  in  addition,  a  second  palmaris 
profunda,  which  formed,  by  joining  the  trunk  of  the  ulnar 
artery,  a  second  deep  palmar  arch. 

"  The  large  ulnar  sent  off  its  recurrent  branches,  a  posterior 
interosseal  artery,  two  anterior  interosseal  arteries,  and  a  long 
muscular  artery.  At  the  wrist  it  sent  off  its  usual  communi- 
cating artery,  and  in  the  palm  of  the  hand,  having  received 


VARIETIES   OF   THE   ABDOMINAL   AORTA.  391 

the  second  deep  palmar  branch  of  the  radial,  it  supplied,  as 
usual,  three  fingers  and  a  half,  without,  however,  forming 
any  superficial  palmar  arch. 

"The  practical  inferences  to  be  deduced  from  these  unusual 
distributions  are  plain,  and  of  some  importance.  Had  this 
individual  been  the  subject  of  illness  during  her  life,  a  very 
erroneous  estimate  of  its  intensity  must  have  been  indicated 
by  the  pulse ;  and  did  the  practitioner  depend  chiefly  on 
its  condition,  his  practice  would  have  been  guided  by  the 
wrist  he  felt  it  at.  Here,  if  the  right  pulse  be  felt,  from  the 
size  of  the  radial,  depletory  measures  would  in  all  likelihood 
have  been  pursued ;  and  were  it  the  left,  an  opposite  mode  of 
treatment  may  have  been  adopted ;  and  if  both  wrists  were 
examined,  they  would,  at  the  least,  have  given  cause  for  de- 
liberation in  the  case. 

"  In  addition  to  the  varieties  of  arteries  always  being,  when 
they  exist,  a  source  of  difficulty  when  a  vessel  is  required  to 
be  secured,  this  individual,  did  she  require  to  have  her  left 
fore-arm  amputated,  would  have  presented  to  the  surgeon  no 
less  than  seven  considerable  arteries  for  the  ligature." 


VARIETIES    OP   THE   ABDOMINAL   AORTA. 

The  aorta  sometimes  bifurcates  at  the  third  lumbar  ver- 
tebra, or  as  high  as  the  second,*  or  immediately  after  giving 
off  the  renal  arteries. f  Dr.  Green  met  with  the  following 
varieties  in  this  vessel : — In  a  child  born  with  imperforate 
anus,  the  aorta  divided  in  the  lumbar  region  into  two  branches ; 
one  of  which  gave  off  the  inferior  mesenteric,  then  crossed 
to  the  back  of  the  bladder,  and  ascended  along  the  median 
line  to  bifurcate  at  the  umbilicus :  the  other  branch,  situated 
behind  the  former,  was  reflected  towards  the  right  sacro-iliac 

*  "  Anatom.  Societ.  a.  g.  Mars,"  1835. 

t  Journal  des  Progres,  1828,  vol.  viii.  p.  191. 


392  VARIETIES   OP   THE   ABDOMINAL   AORTA. 

symphysis :  having  supplied  the  left  side  of  the  pelvis  and 
left  lower  extremity,  the  continuation  of  it  became  the  right 
femoral:  the  arch  of  the  aorta  gave  off  three  branches: 
first,  a  trunk  common  to  both  carotids;  secondly,  a  left  sub- 
clavian; thirdly,  a  right  subclavian,  which  crossed  behind 
the  oesophagus.  The  left  kidney  and  renal  artery  were  want- 
ing. A  case  of  obliteration  of  the  aorta  immediately  below 
its  arch  is  related  by  Dessault.*  It  appeared,  from  examina- 
tion of  the  body,  that  during  life  the  blood  which  was  ex- 
pelled from  the  heart  must  have  been  transmitted  into  the 
trunk  of  the  aorta  below  the  constriction,  by  passing  through 
the  subclavian,  axillary,  and  cervical  arteries.  From  these 
latter  it  passed  into  the  vessels  of  the  thoracic  and  abdominal 
viscera,  and  those  of  the  lower  extremities.  Dr.  Graham,  of 
Glasgow,  published  another  example  of  complete  obstruction 
of  the  aorta  just  below  the  ductus  arteriosus.f  There  are 
several  other  cases  of  this  kind  recorded. 

The  following  instances,  having  occurred  in  the  abdominal 
region,  are  more  to  our  present  purpose.  M.  A.  Severin 
speaks  of  an  obstruction  of  the  aorta  beneath  the  emulgent 
arteries.  Monro  describes  an  obliteration  of  this  vessel  above 
the  common  iliac  arteries.  Crampton  also  saw  it  obliterated 
in  the  abdominal  region ;  and  Larrey  and  Key  have  described 
similar  cases.  Dr.  Goodison,  of  Wicklow,  examined  at  Paris 
the  body  of  a  woman  in  whom  the  aorta  was  obliterated  im- 
mediately beneath  the  inferior  mesenteric  artery.  The  left 
common  iliac  artery  was  impervious  in  its  entire  length,  and 
the  right  common  iliac  in  one-half:  the  limbs  did  not  appear 
at  all  emaciated. J  The  history  of  this  case  could  not  be 
ascertained.  The  late  Sir  P.  Crampton  examined  the  prepa- 
ration, and  was  of  opinion  that  the  obliteration  was  the  effect 


*  Dessault's  Journal,  vol.  ii. 

t  Med.  Chir.  Trans.,  vol.  v.  p.  287. 

X  Dub.  Hosp.  Rep.,  vol.  ii.  p.  193. 


VARIETIES   OF   BRANCHES   OF  ABDOMINAL  AORTA.    393 

of  a  process  by  which  an  aneurism  had  been  spontaneously 
cured.  In  all  the  above  cases,  the  circulation  had  been  esta- 
blished below  the  obstruction;  and  in  none,  except  the  cases 
of  Larrey  and  Key,  did  there  appear  to  have  been  any  weak- 
ness in  the  limbs. 

Varieties  of  the  C(ELIAC  Axis. — The  Coeliac  axis  may 
be  deficient ;  or  it  may  give  off  only  the  hepatic  and  splenic 
arteries;  or  the  hepatic,  splenic,  and  capsular;  or  it  may,  in 
addition  to  its  usual  branches,  give  off  the  phrenic  and  gastro- 
epiploica  dextra,  or  the  superior  mesenteric. 

Varieties  of  the  GtAstric,  or  Coronaria  Yentriculi 
Artery. — This  artery  has  been  found  arising  from  the  aorta, 
in  common  with  one  of  the  phrenics;  and  it  frequently  gives 
a  branch  to  the  liver. 

Varieties  of  the  Hepatic  Artery. — This  has  been 
said  to  be  wanting.  There  may  be  two  hepatic  arteries;  one 
from  the  coeliac  axis,  and  the  other  from  the  aorta,  or  from 
the  gastric  artery.  The  hepatic  artery  may  come  directly 
from  the  aorta  or  from  the  superior  mesenteric  artery.  Acces- 
sary branches  from  the  renal,  or  from  other  sources,  may  be 
expended  in  the  liver. 

Varieties  of  the  Superior  Mesenteric  Artery. — 
This  artery  sometimes  arises  in  common  with  the  coeliac  axis. 
It  has  been  known  to  give  off  an  hepatic  artery,  and  in 
another  case  it  gave  off  the  gastro-epiploica  dextra. 

The  superior  mesenteric  artery  may  be  absent;  or  its  branches 
may  not  anastomose  with  those  of  the  inferior  mesenteric 
artery;  or  it  may  be  double.  In  a  case  of  high  division  of  the 
aorta,  the  superior  mesenterrc  has  come  from  the  internal 
iliac. 


394    varieties  of  branches  of  abdominal  aorta. 

Varieties  of  the  Inferior  Mesenteric  Artery. — 
This  artery  may  be  wanting.  In  a  very  remarkable  case 
where  the  right  kidney  and  its  artery  were  absent,  the 
common  iliac  arteries  were  united  by  a  transverse  branch,  and 
from  the  left  common  iliac  came  off  the  inferior  mesenteric* 

Varieties  of  the  Phrenic  Arteries. — Both  phrenics 
have  been  found  arising  by  a  common  origin  from  the  right 
emulgent;  or  they  may  arise  by  a  common  origin  from  the 
aorta;  or  one  or  both  may  come  from  the  coeliac  axis.  Some- 
times they  arise  from  the  first  lumbar,  but  rarely  from  the 
gastric  or  renal. 

Varieties  of  the  Capsular  Arteries. — These  arteries 
are  very  small  in  the  adult,  but  as  large  as  the  renal  in  the 
foetus :  there  are  often  three  or  four  of  them.  The  supra- 
renal capsules  have  arteries  from  three  different  sources,  viz. : 
from  the  inferior  phrenic,  from  the  aorta,  and  from  the  renal 
arteries. 

Varieties  of  the  Kenal  Arteries. — These  arteries  are 
liable  to  many  varieties,  affecting  their  number,  origin,  direc- 
tion, and  branches  given  off  from  them.  Number. — In  some 
cases  there  are  two  on  one  or  both  sides :  when  this  occurs 
on  the  right  side,  one  branch  usually  goes  behind  and  the 
other  in  front  of  the  inferior  cava.  Occasionally  there  is  a 
distinct  artery  sent  to  one  of  the  extremities  of  the  kidneys; 
this  may  be  either  a  branch  of  the  renal,  or  it  may  arise  sepa- 
rately from  the  aorta,  internal  iliac,  or  middle  sacral,  or  from 
the  common  iliac.  In  one  very  extraordinary  case  the  kidney 
was  placed  transversely  in  the  pelvis  and  supplied  by  the 
middle  sacral  artery .f     Portal  saw  the  right  and  left  arteries 


*  Petsch,  Syl.  Observ.  Anat.  Select.,  §  76. 
f  Archives  G6nerales,  Fev.  1835. 


VARIETIES   OF   THE   COMMON   ILIAC   ARTERY.  395 

arise  by  a  common  origin  from  the  aorta.  The  right  renal 
artery  and  kidney  may  be  absent.  Origin. — The  renal  artery 
may  arise  lower  down  than  usual  from  the  aorta;  or  it  may 
come  from  the  common  or  internal  iliac  :  this  is  more  likely 
to  occur  when  the  kidney  is  found  in  the  iliac  fossa,  as  some- 
times happens.  Cruveilhier  has  seen  an  accessary  branch, 
from  the  bifurcation  of  the  aorta,  go  to  the  kidney  in  this 
situation.  Meckel  has  seen  the  two  renal  arteries  arise  by  a 
common  trunk  from  the  front  of  the  aorta.  Direction. — The 
renal  arteries  usually  form  somewhat  less  than  a  right  angle 
with  the  continued  trunk;  but  their  direction  must  obviously 
vary  according  as  they  rise  high  or  low.  In  some  cases  in 
which  there  were  two  renal  arteries  on  one  side,  they  were 
found  twisted  on  each  other  like  the  umbilical  arteries. 

Branches  from  the  Renal  Arteries. — The  spermatic  arte- 
ries on  one  or  both  sides  may  arise  from  these  arteries. 

Varieties  of  the  Spermatic  Arteries. — The  spermatic 
artery  on  one  or  both  sides  may  come  from  the  renal :  this  is 
more  likely  to  occur  on  the  right  side  than  on  the  left.  Some- 
times they  arise  from  the  aorta  by  a  common  trunk;  and 
Cruveilhier  has  seen  the  left  one  arise  from  the  aorta  as  low 
down  as  the  inferior  mesenteric. 

The  spermatic  artery  may  likewise  arise  from  the  capsular ; 
or  from  the  external  or  internal  iliac ;  or  from  the  lumbar,  or 
even  from  the  epigastric. 

Varieties  of  the  Common  Iliac  Artery. — The  com- 
mon iliac  artery  has  been  known  to  give  off  the  middle  sacral, 
also  the  lateral  sacral,  and  in  some  cases  the  ilio-lumbar.  We 
have  referred  already  to  cases  in  which  the  renal  artery  arose 
from  it,  and  to  another  case,  in  which  the  inferior  mesenteric 
artery  arose  from  the  left  common  iliac. 

Varieties  op  the  Umbilical  Artery. — These  arteries 


396  VARIETIES   OP   THE   OBTURATOR   ARTERY. 

have  been  known  to  unite,  and  form  a  single  trunk,  and  many 
cases  are  recorded  in  which  the  artery  of  one  side  was  absent. 

Varieties  of  the  Obturator  Artery. — The  obturator 
artery  not  unfrequently  comes  off  from  the  epigastric;  and 
fig.  46,  on  page  293,  represents  three  different  routes  which 
it  may  take,  in  order  to  arrive  at  the  obturator  foramen. 
First,  it  may  arise  from  the  internal  iliac,  and  accompany  the 
obturator  nerve;  this  is  its  usual  origin  and  course.  Se- 
condly, it  may  arise  from  the  epigastric,  and  descend,  without 
crossing  the  femoral  ring,  towards  the  obturator  foramen. 
Thirdly,  it  may  arise  from  the  epigastric,  and  get  to  the  inside 
of  the  ring,  by  running  along  its  anterior  margin,  i.e.  along 
Poupart's  ligament.  These  two  last  varieties  are  marked 
G,  G-,  in  the  figure.  It  may  arise  from  the  epigastric  and 
pass  obliquely  along  the  horizontal  ramus  of  the  pubis  inter- 
nally, and  then  dip  into  the  obturator  foramen. 

It  is  evident,  that  it  is  only  when  the  irregular  obturator 
passes  along  the  back  of  Poupart's  ligament,  and  coasts  along 
the  internal  margin  of  the  femoral  ring  in  order  to  reach  the 
obturator  foramen,  that  it  can  be  endangered  in  the  operation 
for  the  relief  of  strangulated  femoral  hernia.  This  pecu- 
liarity in  its  course  was  first  pointed  out  by  Mr.  Wardrop, 
who  relates  two  cases  of  this  kind,  one  seen  by  himself  and 
Dr.  Barclay,  in  Edinburgh ;  and  another  by  himself,  in  Paris.* 

The  obturator  artery  may  also  arise  from  the  external  iliac, 
or  from  the  femoral,  or  by  a  double  root  from  the  internal 
iliac  and  obturator.  Green  relates  a  case  in  which  it  was 
wanting  on  one  side,  and  its  place  supplied  by  branches  of  the 
profunda.  The  preparation  is  in  the  late  Dr.  McCartney's 
museum. 

Varieties  op  the  Pudic  Artery. — The  trunk  of  the 

*  Med.  and  Surg.  Journal  for  1806. 


VARIETIES  OP  THE  ARTERY  OF  THE  BULB,  ETC.  397 

pudic  artery,  in  some  cases,  instead  of  going  out  of  the  pelvis 
through  the  great  sciatic  notch,  descends  along  the  inferior 
surface  of  the  bladder,  and  then  over  the  prostate  gland,  to 
be  distributed  to  the  penis,  or  it  may  keep  close  to  the  outer 
edge  of  the  vesicula  seminalis  and  then  pass  close  to  the  in- 
ferior surface  of  the  corresponding  lateral  lobe  of  the  prostate 
gland  delineated  in  figure  72. 

Fig.  12.— Represents  the  Abnormal  Course  of  the  Left  Internal  Pudic  Artery,  under 
the  left  lobe  of  the  Prostate  {after  Maclise). 


A,  A,  Median  Line  intersecting  B,  B,  dividing  the  deeper  parts  into  Anterior  and  Posterior  Re- 
gions, C,  Incision  showing  that  the  Pudic  Artery  must  be  divided  when  it  runs  this  course.  D,  D, 
Vas  Deferens  of  each  side.  S,  E,  Right  and  Left  Lobes  of  the  Prostate.  P,  Ureter.  H,  H,  Vesiculae 
Seminales. 

Variety  of  the  Artery  of  the  Bulb. — This  artery 
may  arise  far  back  from  the  pudic,  opposite  to  the  tuber 
ischii,  and,  running  in  a  tortuous  direction  internally,  may 
thus  reach  its  destination.  This  variety  is  delineated  in 
figure  73. 


Varieties  op  the  Dorsal  Artery  op  the  Penis. — 
This  artery  sometimes  comes  directly  from  the  iliac,  and 
passes  along  the  side  of  the  prostate  gland,  to  arrive  at  its 

34 


398 


VARIETIES    OF    THE    ILIO-LUMBAR   ARTERY. 


destination.     The  late  Dr.  M'Dowel  remarked  that  this  va- 
riety was  more  frequent  on  the  left  than  on  the  right  side. 

Dr.  Green  has  seen  the  dorsal  artery  arising  from  the  obtu- 
rator, which  was  given  off  from  the  femoral  a  little  below 
Poupart's  ligament.     Cruveilhier  has  seen  the  dorsal  artery 

Fig.  IS.— Represents  the  Surgical  Anatomy  of  the  Male  Perineum,  the  Artery  of  the 
Bulb  arising  farther  back  than  usual,  nppo^it-e  the  Tuber  Ischii  {after  Maclise). 


A,  A,  Median  Line,  intersecting  B,  B,  dividing  the  Perineum  into  the  Anterior  and  Posterior  Re- 
gions. C,  D,  Lines  showing  the  course  of  ncisions  which  would  divide  the  Artery  of  the  Bulb  in  a 
case  of  this  Abnormal  Origin  ;  or  the  Internal  Pudic  Artery  in  case  the  incision  be  carried  too  far 
outwards.  An  incision,  which  C  represents,  would  also  divide  the  Artery  of  the  Bulb  in  its  Normal 
Situation. 

of  the  penis  arise  from  the  superficial  or  external  pudic,  near 
the  aperture  for  the  saphena  vein,  and,  after  forming  a  curva- 
ture in  the  groin,  with  its  convexity  turned  downwards,  pro- 
ceed along  the  lateral  surface  of  the  penis.  In  another  case, 
in  addition  to  its  usual  root,  which  was  diminutive,  it  had  a 
second  of  considerable  size,  which  arose  from  the  obturator 
artery,  and  passed  under  the  symphysis  pubis,  to  join  the 
former. 


Varieties  of  the  Ilio-Lumbar  Artery. — This  vessel 
not  unfrequently  comes  from  the  glutaeal :  sometimes  it  is 
double, — its  iliac  and  lumbar  branches  arising  separately.  Its 
size  often  seems  to  depend  on  the  number  of  lumbar  arteries; 


VARIETIES   OF   THE   FEMORAL   ARTERY.  399 

the  ilio-lumbar  being  small  whenever  there  happens  to  be  a 
fifth  lumbar  artery. 

Varieties  of  the  Lateral  Sacral  Artery. — This 
artery  sometimes  arises  from  the  ilio-lumbar,  and  frequently 
from  the  glutaeal.  Occasionally,  instead  of  forming  an  arch 
inferiorly,  it  terminates  by  entering  the  last  sacral  foramen. 

Varieties  of  the  Middle  Hemorrhoidal  Artery. — 
This  artery  sometimes  comes  from  the  pudic  before  it  leaves 
the  pelvis;  sometimes  from  the  sciatic  artery,  and  occasion- 
ally it  is  wanting. 

Varieties  of  the  Uterine  x\rtery. — This  vessel  some- 
times arises  from  the  internal  pudic. 

Varieties  of  the  Vaginal  Artery. — This  artery  is 
very  irregular ;  it  may  be  wanting,  or  it  may  come  from  the 
uterine,  pudic,  middle  haemorrhoidal,  or  even  from  the  obtu- 
rator. 

Varieties  of  the  Epigastric  Artery. — This  artery 
may  arise  higher  up  than  usual ;  or  it  may  arise  in  common 
with  the  obturator,  or  from  the  upper  part  of  the  femoral,  or 
from  the  profunda  femoris. 

Varieties  of  the  Circumflexa  Ilii  Artery. — This 
vessel  is  sometimes  double.  It  may  arise  from  the  femoral 
or  from  the  epigastric. 

VARIETIES   OF   THE   FEMORAL   ARTERY. 

This  artery  is  sometimes  double :  Gooch  has  cited  three 
examples ;  Velpeau  mentions  a  fourth,  and  refers  to  Casa- 
mayor,  who  saw  a  fifth.  In  Velpeau's  case  the  supernume- 
rary artery  gave  off  the  branches  usually  given  off  by  the 


400        VARIETIES   OF   THE   PROFUNDA   FEMORIS,  ETC. 

profunda ;  and  its  peculiarity  seems  to  consist  in  its  having 
afterwards  preserved  sufficient  size  to  descend  below  the  knee. 
Sir  C.  Bell  found  the  femoral  artery  dividing  into  two  equal 
trunks,  which  afterwards  united  to  form  the  popliteal :  Mr. 
Houston  has  described  a  similar  instance.  Another  variety 
consists  in  a  high  bifurcation  of  the  vessel.  Sandifort  relates 
a  case  in  which  the  artery  divided  a  little  below  Poupart's 
ligament  into  two  vessels,  the  continuations  of  which  were  the 
posterior  tibial  and  peroneal  arteries ;  and  Portal  refers  to  a 
case  in  which  it  divided  high  up  in  the  femoral  region  into 
two  vessels,  the  continuations  of  which  formed  two  popliteal 
arteries. 

Varieties  of  the  Profunda  Femoris. — This  artery 
sometimes  arises  within  the  pelvis  from  the  external  iliac; 
this  is  its  regular  origin  in  birds.  In  the  case  in  which  Mr. 
James  tied  the  aorta,  the  profunda  arose  above  Poupart's 
ligament  and  gave  oflf  the  epigastric. 

Varieties  of  the  External  Circumflex  Femoris. — 
This  artery  may  arise  after  the  internal  circumflex,  or  in 
common  with  it;  or  it  may  arise  from  the  femoral,  or  be 
large  enough  to  appear  as  a  branch  of  bifurcation  from  the 
profunda. 

Varieties  of  the  Internal  Circumflex  Femoris. — 
This  vessel  sometimes  comes  off  before  the  external  circum- 
flex; sometimes  directly  from  the  femoral,  sometimes  from 
the  external  iliac,  or  it  may  arise  by  a  common  trunk  with 
the  external  circumflex. 

Varieties  of  the  Popliteal  Artery. — The  principal 
varieties  of  this  artery  are  included  in  those  of  the  femoral. 
We  have  only  to  add  that  the  popliteal  artery  sometimes 
divides  at  one  point  into  three  branches;  viz.:  the  anterior 


VARIETIES  OP  THE  ANTERIOR  TIBIAL  ARTERY,  ETC.      401 

and  posterior  tibial,  and  fibular.  In  a  remarkable  case  referred 
to  by  Dr.  Green,  the  popliteal  artery  was  a  continuation  of  the 
sciatic,  the  femoral  having  terminated  at  the  knee-joint.  In 
this  case  the  internal  iliac  artery  was  much  larger  than  the 
external.  Either  the  two  superior  or  the  two  inferior  articular 
branches  may  arise  by  a  common  trunk. 

Varieties  of  the  Anterior  Tibial  Artery. — This 
artery  may  arise  above  the  popliteus  muscle  and  descend 
across  it.  Or  when  it  has  arrived  in  the  anterior  region  of 
the  leg,  Pelletan  observes  that  it  may  descend  immediately 
under  the  integument  and  not  between  the  muscles.  In  some 
instances  it  may  be  expended  at  the  lower  part  of  the  leg,  and 
its  place  on  the  dorsum  of  the  foot  supplied  by  the  anterior 
peroneal;  or  the  artery  may  be  altogether  absent,  in  which 
case  its  place  is  supplied  by  perforating  branches  of  the  pos- 
terior tibial. 

Varieties  of  the  Posterior  Tibial  Artery. — This 
vessel  may  be  deficient,  and  its  place  supplied  by  branches 
of  the  fibular,  or  there  may  be  two  in  the  same  limb,  as  ob- 
served by  Dr.  Green,  or  it  may  arise  higher  or  lower  than 
usual. 

Varieties  op  the  Peroneal  Artery. — We  have  already 
seen  that  the  anterior  peroneal  artery  may  be  of  considerable 
size,  and  may  take  the  place  of  the  anterior  tibial  upon  the 
dorsum  of  the  foot;  giving  off  the  tarsal,  metatarsal,  dorsalis 
pollicis,  and  communicating  branches.  In  such  cases  there 
is  an  arrest  of  development  of  the  anterior  tibial  artery,  so 
that  its  termination  on  the  dorsum  of  the  foot  is  exceedingly 
diminished  in  size,  and  anastomoses  directly  with  the  above 
variety  of  the  anterior  peroneal. 

the  end. 


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discharge  of  Soldiers  from  service  on  Surgeon's  Certificate. 
Adapted  to  the  service  of  the  United  States.  By  Thomas  Hen- 
derson, M.D.,  Asst.  Surgeon  U.S.  Army.  A  new  edition,  revised 
by  EiCHARD  H.  CooLiDGE,  M.D.,  Asst.  Surgeon  U.S.  Army.  1 
vol.  12mo.    $1.00. 

A  Manual  of  Military  Surgery;  or.  Hints  on  the  Emergen- 
cies of  Field,  Camp,  and  Hospital  Practice.  By  S.  D.  Gross, 
M.D.,  Professor  of  Surgery  in  the  Jefferson  Medical  College  of 
Philadelphia.     1  vol.  18mo.     50  cents. 


J.  B.  LIPPINCOTT  &   CO.'S   MILITARY  PUBLICATIONS,     5 

Oavalry  Tactics  •  Published  by  order  of  the  War  Department. 
First  Part. — School  of  the  Trooper,  of  the  Platoon  and  of 
the  Squadron  Dismounted.  Second  Part. — Of  the  Platoon  and 
of  the  Squadron  Mounted.  Third  Part. — Evolutions  of  a 
Regiment.    3  vols.  18mo.    $3.75. 

War  Department,  Washington^  Feb.  10,  1841. 
The  system  of  Cavalry  Tactics  adapted  to  the  organization  of  Dra- 
goon regiments,  having  been  approved  by  the  President  of  the  United 
States,  is  now  published  for  the  government  of  the  said  service. 

Accordingly,  instruction  in  the  same  will  be  given  after  the  method 
pointed  out  therein ;  and  all  additions  to,  or  departures  from,  the  ex- 
ercises and  manoeuvres  laid  down  in  this  system  are  positively  for- 
bidden. J.  R.  POINSETT,  Secretary  of  War. 

Instruction  in  Field  Artillery.  Prepared  by  a  Board  of 
Artillery  Officers.     1  vol.  demi-Svo.    $2.50. 

Baltimore,  Md.,  Jan.  15,  1859. 
Col.  S.  Coopeb,  Adjt.  Gen.  U.S.A. 

Sir  : — The  Light  Artillery  Board  assembled  by  Special  Orders  No. 
134,  of  1856,  and  Special  Orders  No.  116,  of  1858,  has  the  honor  to 
submit  a  revised  system  of  Light  Artillery  Tactics  and  Regulations 
recommended  for  that  arm. 

WM.  H.  FRENCH,  Bt.  Major,  Captain  First  Artillery. 
WILLIAM  F.  BARRY,  Captain  Second  Artillery. 
HENRY  J.  HUNT,  Bt.  Major,  Captain  Second  Artillery. 

War  Department,  March  6,  1860. 
The  system  of  instruction  for  Field  Artillery,  prepared  by  a  Board 
of  Light  Artillery  Officers,  pursuant  to  orders  from  this  Department, 
having  been  approved  by  the  President,  is  herewith  published  for  the 
information  and  government  of  the  army. 

All  exercises,  manoeuvres,  and  forms  of  parade  not  embraced  in  this 
system  are  prohibited  in  the  Light  Artillery,  and  those  herein  pre- 
scribed will  be  strictly  observed. 

By  order  of  the  Secretary  of  War. 

The  Handy-Book  for  tlie  United  States  Soldier,  on  coming 

INTO  Service.  Containing  a  Complete  System  of  Instruction 
in  the  School  of  the  Soldier ;  embracing  the  Manual  for  the 
Rifle  and  Musket,  with  a  preliminary  explanation  of  the  Form- 
ation of  a  Battalion  on  Parade,  the  Position  of  the  Officers, 
&c.  &c.  Also,  Instructions  for  Street-Firing.  Being  a  First 
Book  or  Introduction  to  the  authorized  United  States  Infantry 
Tactics.     Complete  in  1  vol.  128  pages,  illustrated.     25  cents. 

To  the  recruit  just  mustered  into  service,  the  system  of  tactics  seems 
extensive  and  difficult. 

The  design  of  this  little  Handy-Book  is  to  divide  the  instruction,  and, 
by  presenting  a  complete  system  for  the  drill  of  the  individual  soldier, 
to  prepare  him  for  the  use  and  study  of  the  authorized  United  States 
Infantry  Tactics,  in  the  school  of  the  company  and  the  battalion. 


6      J.  B.  LIPPINCOTT   &   CO.'S   MILITARY  PUBLICATIONS. 

Evolutiona  of  the  Line,  Field  Manual  of  Evolutions  of  the 
Line,  arranged  in  a  tabular  form,  for  the  use  of  officers  of  the 
United  States  Infantry;  being  a  sequel  to  the  authorized 
United  States  Infantry  Tactics.  Translated,  with  adaptation 
to  the  United  States  Service,  from  the  latest  French  author- 
ities, by  Captain  Henry  Coppjee,  late  Instructor  in  the  United 
States  Military  Academy  at  West  Point.     18mo.     50  cents. 

From  Brigadier- General  J.  K.  A.  Mansfield,  U.S.A. 

I  received  in  due  time  your  little  book  of  the  **  Evolutions  of  the 
Line."  I  am  delighted  with  it.  It  is  the  best  thing  of  the  kind  I  have 
seen.  It  is  concise,  to  the  point  in  every  particular,  and  deserves  the 
exclusive  patronage  of  the  Government. 

Manual  of  Battalion  Drill.  The  Field  Manual  of  Battalion 
Drill,  containing  all  the  movements  and  manoeuvres  in  the 
School  of  the  Battalion,  with  the  commands  arranged  in  tabu- 
lar forms  and  properly  explained.  Translated  from  the 
French,  with  adaptation  to  the  United  States  Service,  by  Cap- 
tain Henry  Coppee,  late  Instructor  in  the  United  States  Mili- 
tary Academy  at  West  Point.     18mo.     50  cents. 

From  General  George  A.  McCall,  U.S.A. 

Thank  you  for  the  two  beautiful  little  volumes, — "The  Field  Manual 
of  Battalion  Drill,"  and  the  "Field  Manual  of  Evolutions  of  the  Line." 
I  have  examined  them  with  great  care,  and  I  have  much  pleasure  in 
assuring  you  that  in  my  estimation  you  have  brought  forth  the  very 
best  thing  of  its  kind  that  could  possibly  have  been  produced  at  this 
particular  time.  Greatly  condensed,  it  is  still  full  enough  to  satisfy 
the  student,  and  is,  in  fact,  the  best  vade-mecum  I  have  ever  seen. 

From  General  John  E.  Wool,  U.S.A. 

I  am  greatly  obliged  for  the  volumes  of  your  "  Field  Manual  of  Bat- 
talion Drill"  and  "Evolutions  of  the  Line."  The  arrangement  is  no 
less  admirable  than  it  is  well  calculated  to  aid  the  officer  in  acquiring 
with  ease  and  facility  the  "battalion  drill,"  as  well  as  the  "evolutions 
of  the  line."  Altogether,  I  think  them  the  best  Field  Manuals  I  have 
ever  seen.  I  hope  the  whole  army  will  be  furnished  with  both 
volumes. 

Manual  for  Courts-Martial,  a  Manual  for  Courts-Martial, 
containing  full  Explanations  of  the  Duties  of  all  Officers  em- 
ployed on  such  Service,  with  complete  Forms  of  Proceedings. 
By  Captain  Henry  Coppice,  late  Instructor  in  the  United  States 
Military  Academy  at  West  Point.     (Nearly  ready.) 


ii-iiuW"'"""'r 


UNIVERSITY  OF  CALIFORNIA 

Medical  Center  Library 

THIS  BOOK  IS  DUE  ON  THE  LAST  DATE  STAMPED  BELOW 

Books  not  returned  on  time  are  subject  to  a  fine  of  50c  per  volume  after 
the  third  day  overdue,  increasing  to  $1.00  per  volume  after  the  sixth  day. 
Books  not  in  demand  may  be  renewed  if  application  is  made  before  ex- 
piration of  loan  period. 


JUL  1  2  1994 
RETURNED 

m  2  8  m 


5m-3,'47(A2646s2)4128 

Brigadier-General  U.S.  Army.     In  two  vols.  18mo.     Price  $1.50.  Jji 

Eevised  Army  Ee^ations.    Revised  Regulations  for  the  Army  of  I, 

the  United  States,  1861.     By  authority  of  the  President  of  the  United  ^ 

States  and  the  Secretary  of  War.     With  a  full  Index.     Just  pub-  j(| 
lished.     One  vol.  8vo. 


11  —       •        •  I 


'iHSiii 


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^-v-^. 


MILITARY   PUBLICATIONS. 


!^i(v!i^\\\\! 


Field  Artillery.  Instruction  in  Field  Artillery.  Prepared  by  a  Board 
of  Artillery  Officers.     One  vol.  8vo.     $2.50. 

Hardee's  Tactics,  Rifie  and  Light  Infantry  Tactics,  for  the  Exercise 
and  Manoeuvres  of  Troops  when  acting  as  Light  Infantry  or  Rifle- 
men. Prepared  under  the  direction  of  the  War  Department.  By 
Brevet  Lieutenant-Colonel  W.  J.  Haedee,  U.S.A.  Two  vols,  com- 
plete.    $1.60. 


ii 


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